5211 

FUNCTIONAL 
NEEV0U8  DISEASES 

THEIE  CAUSES  AND  THEIE  TREATMENT 


MEMOIR  FOR  THE  CONCOURSE  OF  1881-18S3 

acad:^mie  ROY  ale  de  M^DEGINE  de  belgique 


WITH  A  SUPPLEMENT 

ON  THE  ANOMALIES  OF  REFRACTION  AND  ACCOMMODATION 

OF  THE  EYE  AND   OF  THE  OCULAR  MUSCLES 


BY 

GEOEGE  T.    STEVENS,   M.  D.,   Ph.  D. 

MEMBER     OF    THE     AMERICAN     MEDICAL   ASSOCIATION,    OF   THE    AMERICAN     OPHTHAL- 

MOLOGICAI,     SOCIETY  ;     FORMERLY    PROFESSOR    OF   OPHTHALMOLOGY    AND 

PHYSIOLOGY    IN    THE    ALBANY   MEDICAL    COLLEGE 


Traditionem  pondero,  doctrinam  resplcio,  sequor  veritatem 


NEW  YORK 
D.    APPLETON    AND    COMPANY 

1887 


COPTRIGHT,  1S8T, 

By  D.  APPLETON  AND  COMPANY. 


loo 


TO 

Db.  E.  LAXDOLT, 

OF   PAEI9, 

■WHOSE   MAXT   VALUABLE   C0XTE1BUTI0N9, 

TO   THE   SUBJECTS    OF 

MUSCULAR    AND    OF    EEFEACTIVE    ANOMALIES    OF    THE    EYES, 

HAVE   ENEICHED   THE   LITEEATUBE    OF    OPHTHALMOLOGY, 

THIS   VOLUME   13   INSCEIBED, 

AS     A     TOKEN    OF     HIGHEST     ESTEEM 

AND   OF   SINCEBE   FEIENDSHIP, 

BY   THE  AUTHOE. 


PREFACE. 


This  memoir,  which  received,  from  1' Academic 
Royale  de  Medecine  of  Belgium,  the  highest  honor 
awarded  for  the  competition  of  1881-1883,  is  now  pre- 
sented in  the  English  as  it  was  then  in  the  French  lan- 
guage. 

The  thesis  for  the  concourse  was,  ";6lucider  par 
des  faits  cliniques  et  au  besoin  par  des  experiences 
la  pathogenic  et  la  therapeutique  des  maladies  des 
centres  nerveux  et  principalement  de  I'epilepsie." 

Since  this  memoir  was  received  by  the  Royal 
Academy,  in  December,  1883,  many  new  views  and 
experiences  have  presented  themselves  to  the  author, 
which  he  would  have  gladly  included  in  this  edition 
of  the  work. 

This  would  have  been  inconsistent  with  the  plan 
of  giving  it  substantially  in  all  particulars  as  it  was 
submitted  to  the  distinguished  body  which  had  al- 
ready passed  judgment  upon  it.  It  has  been  thought 
best  to  shorten  the  work  in  certain  measure,  and  in 


vi  PREFACE. 

the  revision  thus  made  necessary  the  original  form 
has  been  retained  in  every  particular  as  far  as  possi- 
ble, and  while  in  a  few  instances  such  revisions  have 
been  made  as  were  rendered  necessary  by  the  haste 
in  which  the  original  manuscript  was  prepared,  the 
views  and  methods  maintained  in  the  original  have 
been  strictly  preserved,  without  modification. 

In  order  to  introduce  reproductions  from  photo- 
graphs of  some  typical  cases  of  neuroses  in  which 
the  striking  changes  of  physiognomy  resulting  from 
a  relief  to  the  tension  of  the  eye-muscles  in  such 
cases  is  shown,  the  histories  of  these  cases  have  been 
introduced.  These  histories,  not  in  the  original  mem- 
oir, and  obtained  since  its  presentation  to  the  Eoyal 
Academy,  are  indicated  by  brackets  [  ],  which  in  each 
instance  permit  them  to  be  recognized  as  new  ma- 
terial. 

By  an  unfortunate  occurrence,  all  the  negatives 
from  which  these  photograveurs  were  to  have  been 
made  were  destroyed  by  fire  while  the  work  was 
being  executed.  It  then  became  necessary  to  re- 
produce the  portraits  from  very  indifferent  prints. 
Under  these  discouraging  circumstances  the  result, 
although  quite  different  from  what  was  at  first  hoped, 
has  been  much  better  than  might  have  been  expected. 

The  supplemental  portion  of  the  work  has  been 
added,  not  for  the  expert  in  ophthalmology,  but  for 


PREFACE.  vii 

tlie  general  practitioner  who  would  like  to  make  suck 
examinations  of  ocular  conditions  as  will  enable  him 
intelligently  to  advise  and  to  treat  his  patients  af- 
fected with  nerv'ous  complaints.  That  part  of  the 
supplement  devoted  to  refraction  and  accommodation 
is  made  as  comprehensive  as  possible  consistent  with 
brevity.  In  the  treatment  of  muscular  anomalies, 
much  that  is  not  to  be  found  in  the  text-books  on 
the  affections  of  the  eye  is  given.  The  subject  has, 
in  text-books,  received  but  meager  attention,  quite 
insufficient  to  afford  valuable  assistance  to  one  who 
would  attempt  the  treatment  of  nervous  complaints 
by  removal  of  muscular  defects.  While  the  subject 
is  treated  here  only  in  outline,  it  is  hoped  that  the 
student  of  this  subject  will  find  here  a  better  guide 
than  has  been  elsewhere  offered. 

The  author  is  indebted  to  the  publishers  for  the 
skill  with  which  the  difficulties  attending  the  repro- 
duction of  the  portraits  were  overcome,  and  for  the 
excellent  manner  in  which  they  have  presented  the 
work. 

33  "West  Thiety-thied   Steekt, 
New  Yoek,  May,  1887. 


COI^TEN"TS. 


PAGE 

Inteoductton 5-11 

Statement  of  Principles 13-35 

Division  of  Nervous  Affections  into  Functional  and  Organic  13 

Immediate  and  Predisposing  Causes 14 

Neuropathic  Predisposition 15 

Hereditary  Tendency 16 

Modifying  Tendencies 17 

Reflex  Irritations 19 

General  Proposition 21 

The  Eye  as  an  Irritating  Cause 23 

Theory  of  the  Adjustments  of  the  Eyes         ....  22-30 

Practical  Illustrations 31-35 

Cephalalgia,  or  Headache 35-50 

General  Symptoms 35-37 

Attendant  Symptoms  not  Causative 37 

Nervous  Symptoms  Interchangeable 39 

Illustrative  Cases 40, 41 

General  Results  of  Treatment 47-50 

Migraine,  or  Sick-Headache 50-60 

Symptoms 50 

Etiology 53 

Influence  of  Ocular  Defects 53 

Illustrative  Cases     ..........  54r-60 

Neuralgia GO-81 

Definition 61 

General  Characteristics 61 

Points  Douloureux 63 

Migraine  Interchangeable  with  other  Neuroses      ...  65 

Neuralgia  no  Pathology 65 

Immediate  Causes 66 

Predisposing  Causes 67 


X  CONTENTS. 

PAGE 

Influence  of  Ocular  Anomalies  in  causing  Neuralgia     .        .  68 

Results  from  Eelief  of  Ocular  Conditions      ....  69 

Illustrative  Cases 70-76 

General  Propositions  respecting  Neuralgia    ....  76 

Table  showing  Neuralgic  and  Ocular  Conditions  ...  77 

Summary  of  Table  . 78 

Question  of  Heredity  in  Neuralgia 80 

Spinal  Irritation  and  Neurasthenia 81-87 

Nearly  Allied  Forms  of  Neuroses 81 

Mimoses 82 

Pathology  of  Spinal  Irritation  not  demonstrated  ...  83 

Influence  of  Neuropathic  Predisposition  in  Neurasthenia     .  83 

Illustrative  Cases 83-87 

Chorea 87-101 

Bearing  of  some  Characteristic  Features  on  its  Etiology  and 

Treatment 87 

Chorea  among  Hyperopic  Children 89 

Dilatation  of  the  Pupils  in  Chorea 90 

Proportion  of  Ocular  Anomalies  in  Cases  of  Chorea      .        .  91 

Statements  of  Cure  in  Cases  of  Acute  Chorea  of  Little  Value  92 

Results  of  Treatment  in  Chronic  Cases  Significant        .        .  93 

Illustrative  Cases 93-100 

Indications  for  Treatment  of  Chorea 101 

Epilepsy 101-120 

No  Pathology  in  Idiopathic  Epilepsy 102 

Existing  Doctrines  respecting  the  Etiology  Unsatisfactory  .  102 

Heredity  as  Predisposing  Cause 102 

Nature  of  the  Hereditary  Tendency 103 

Ocular  Conditions  in  Epilepsy 104 

Results  of  Treatment  of  Ocular  Defects  in  Epilepsy      .        .  106 

Illustrative  Cases 107-120 

Mental  Disorders 120-124 

Recovery  upon  Relief  of  Ocular  Conditions   ....  121 

Illustrative  Cases 121-124 

Conditions  of  Eyes  to  be  examined  in  Mental  Disorders       .  124 

Heredity 124-131 

Construction  of  the  Eyes  constitutes  an  Important  Element 

in  Heredity .  124 

The  Eyes  as  a  Part  of  the  Facial  Features     ....  125 
Excessive  Demands  upon  the  Nervous  Energies  from  Diffi- 
cult Adjustment  of  the  Eyes 126 

Similar  Irritations  do  not  always  react  in  the  Same  Manner  126 

Supposed  Increase  of  Nervous  Disorders  in  Modern  Thnes  .  127 

History  of  Diseases  in  Neurotic  Families        ....  127 


CONTENTS.  xi 

PAGE 

Study  of  the  Record  of  Diseases  in  Families  with  High  Re- 
fractive Errors 131 

The  Treatment  of  Nervous  Diseases 131-138 

Ocular  Conditions  should  occupy  a  Prominent  Place     .        .  131 

Medicines  have  a  Certain  Value 131 

Certain  Familiar  Principles 132 

Spontaneous  Cures 132 

Prisms  for  Gymnastic  Exercise 133 

Insufficiency  of  the  Externi 134 

Operations  for  Relief  of  Insufficiency  of  External  Recti        .  135 

Method  of  Operation 136 

Employment  of  Extract  of  Calabar  Bean        ....  137 

Employment  of  Atropia  . 138 

Prevalence  of  Refractive  Errors  among  School-Children       .  138 

Dangers  of  Xeglect  of  Such  Conditions 138 

Table  coxtaixixg  Records    of  Diseases  ix  Families  with 

Marked  Refractive  Errors 139-147 

Summary  of  above  Table 146 


SUPPLEMENT. 

Knowledge  of  Refraction  and  Muscular  Anomalies  Essential  to 

the  Successful  Treatment  of  Nervous  Complaints          .  148 

Refractiox  and  the  Accommodation  op  the  Eye    .        .        .  149-156 

The  Eye  as  an  Optical  Instniment 149 

Dioptric  System 149 

Construction  of  the  Ideally  Normal  Eye         ....  149 

Theory  of  Accommodation 151 

Range  of  Accommodation 155 

Refraction  of  the  Eye       .        , 156-157 

Emmetropic  Eye 156 

Hypermetropic  Eye 156 

Myopic  and  Astigmatic  Eye 157 

Hyperopia,  or  Far-Sight 157-160 

Depends  on  the  Form  of  the  Eye 157 

Accommodative  Asthenopia 153 

Symptoms  and  Results  of  Hyperopia  due  to  Fatigue  of  Ac- 
commodation      158 

Symptoms  of  Accommodative  Asthenopia      ....  159 

Latent  and  Manifest  Hyperopia 159 

Myopia,  or  Near-Sight 160-165 

Myopia  dependent  on  the  Anatomical  Formation  of  the  Eye  160 


xii  CONTENTS. 

PAGE 

Popular  Errors  in  regard  to  Near-Sight         ....  161 

Myopia  Progressive 163 

Pathological  Conditions  in  Myopia 163 

Spasm  of  Accommodation 163 

Myopia  prevalent  among  the  Educated  Classes      .        .        .  164 
Relations  of  the  Ocular  Muscles  an  Important  Predisposing 

Cause 165 

Astigmatism 165-167 

Nature  of  Astigmatism 165 

Hyperopic  Astigmatism 166 

Myopic  Astigmatism 166 

Compound  Astigmatism 167 

Mixed  Astigmatism 167 

General  Effects  of  Astigmatism 167 

Examination  and  Treatment  of  Ametropia — Test-Types       .    168-183 

Principle  for  the  Construction  of  Test-Types         .        .        .  168 

Testing  Acuteness  of  Vision 168 

Test-Types  for  Near  Vision 168 

Snellen's  Test-Types 169 

Dioptric  System       .        . 170 

The  Ophthalmoscope  in  the  Diagnosis  of  Ametropia     .        .  171 

The  Author's  Case  of  Trial-Lenses 173 

Method  of  ascertaining  the  Refractive  Condition  of  the  Eye  173 

Tests  for  Astigmatism 178 

Glasses  for  Correction  of  Astigmatism 180 

Formulae  for  Correcting-Lenses 181 

Unequal  Refraction  of  the  Eyes  (Anisometropia)         .        .  183 

Treatment  of  Presbyopia 183 

Presbyopia  not  due  to  Flattening  of  the  Eyeball   .        .        .  183 

Determining  the  Degree  of  Presbyopia 183 

Donder's  Table  for  Presbyopia 184 

Complications  of  Presbyopia 184 

Subjects  of  Interest   relating  to  Refraction  and  Accom- 
modation    186 

A  Few  Pojjular  Errors 186 

Colored  Glasses 187 

Pebbles 187 

Frames  for  Eye-Glasses  and  Spectacles  .        .        .        .        .  187 

Prejudice  against  Employment  of  Glasses  for  Presbyopia     .  188 

Affections  of  the  Ocular   Muscles  in  which    Binocular 

Vision  may  be  maintained 188-317 

Complicated  Systems  of  Muscles  co-operating  in  Binocular 

Vision '     .        •  188 

Nature  of  Binocular  Vision 189 


CONTENTS.  xiii 

PAGE 

Division  of  Affectioxs  of  Ocular  Muscles  into  Two  Great 

Classes 189 

Subdivision  of  one  of  these  Classes 190 

Strabismus 190 

Insufficiencies  of  the  Ocular  Muscles 190 

New  System  of  Terms 190 

Heterophoria 191 

Teachings  of  Graefe  and  others  in  this  Department       .        .  191 

Orthophoria 192 

Esophoria,  Exophoria,  and  Hyperphoria        ....  193 

Hyperesophoria  and  Hyperesophoria 193 

Methods  of  recording  Heterophoria 193 

Method  of  examining  the  Condition  of  Ocular  Muscles         .  193 

Graefe's  Test  for  Insufficiency  of  the  Interni         .        .        .  198 

Standard  of  Abduction 198 

Sursumduction 199 

Standard  of  Adduction 199 

Hyperphoria 200-203 

Definition 200 

Difference  between  Hyperphoria  and  Strabismus  .        .        .  200 

Importance  of  Hyperphoria 200 

Complications  arising  from  Hyperphoria       ....  201 

General  Symptoms  arising  from  Hyperphoria        .        .        ,  201 

Attitudes  and  Facial  Expression  in  Hyperphoria  .        .        .  203 

Vision  in  this  Condition 203 

Abnormal  Secretion  of  Tears  resulting  from  Hyperphoria    .  203 

Eeflex  Results 203 

Treatment  of  Hyperphoria 208-206 

Highest  Skill  of  the  Surgeon  demanded         ....  203 

Method  of  performing  Tenotomy  of  Eye-Muscles         .        .  203 

EsoPHORiA 204-208 

Slight  Attention  in  the  Literature  of  Ophthalmology  given 

to  this  Condition 204-206 

Symptoms  resulting  from  Esophoria 207 

Method  of  determining  Esophoria 208 

Treatment  of  Esophoria 210 

Exophoria 210-214 

Exophoria  and  Insufficiency  of  the  Interni    ....  210 

Method  of  discovering  Exophoria 211 

General  Symptoms  from  Exophoria 211 

Exophoria  and  Myopia 213 

Adducting  Power 213 

Treatment  of  Esophoria 214-217 


lE^TEODUCTIOIsr.* 


Paitts  spreading  to  parts  contiguous  to  tlie  eyes,  as 
the  result  of  strain  to  those  organs,  in  much  the  same 
manner  as  pain  from  a  wound  extends  to  the  environ- 
ing tissues,  have  long  been  observed.  In  many  of  the 
older  treatises  on  the  diseases  of  the  eye,  headaches, 
nausea,  and  vertigo  are  mentioned  as  parts  of  that 
group  of  symptoms  which  we  now  designate  as  as- 
thenopia. 

It  is  to  be  remembered  that  the  phenomena  of  ac- 
commodative asthenopia,  while  recognized,  were,  until 
its  nature  and  causes  were  more  fully  explained  by 
Bonders  in  his  remarkable  work  published  in  1864, 
described  under  different  names,  such  as  Tiebetudo 
visus,  amblyopie  presbytique,  etc.,  and  were  by  many 
supposed  to  possess  a  distinct  pathology,  such  as  hy- 
persemia  of  the  retina,  or  an  increase  of  some  of  the 
humors  within  the  eye.  There  was  a  general  agree- 
ment, however,  in  the  grouping  of  the  phenomena  and 
in  regarding  excessive  or  disadvantageous  use  of  the 
eyes  themselves  as  the  exciting  cause.  The  groujDing 
consisted,  as  it  now  consists,  of  pain,  tension  in  the 

*  Submitted  to  the  Eoyal  Academy  of  Medicine,  July,  1886. 


6  INTRODUCTION. 

forehead,  dazzling  and  confusion  of  vision,  inability 
to  continue  the  use  of  the  eyes,  to  which  by  many 
authors  were  added  the  more  general  sensations  of 
dizziness,  nausea,  headaches  in  other  parts  of  the  head 
than  the  forehead,  and  general  malaise. 

Antoine  Maltre-Jan*  (1707)  gives  a  good  descrip- 
tion of  the  complaint,  which  he  thinks  arises  from  in- 
creased intra-ocular  tension  resulting  from  strain  of 
the  eyes.  A  century  later,  Weller  f  (1832)  enumerates 
tension  over  the  eyes,  headaches,  nausea,  and  vertigo, 
to  which  train  of  phenomena  Sichel  %  (1837)  adds  in- 
somnia, as  the  group  of  symptoms  arising  from  ex- 
cessive use  of  the  eyes. 

An  old  author,  *  in  speaking  of  the  people  who 
require  glasses  for  reading,  but  neglect  to  use  them, 
remarks  facetiously,  "Their  eyes  ache,  their  head 
aches,  and  every  bit  of  'em  aches."  Piorry^  (1850) 
quotes  from  his  writings  twenty  years  earlier,  his 
views  regarding  certain  nervous  disturbances,  '■'■oscil- 
lations nerveuses''''  having  their  seat  in  the  eye,  the 
ear  or  in  some  branches  of  the  fifth  nerve. 

A  form  of  migraine  which  he  calls  ^Hrisalgie''^  has, 
according  to  him,  its  origin  in  irritation  arising  either 
from  the  iris  or  from  the  retina.  The  migraine  results 
in  such  cases  from  excessive  or  improper  use  of  the 
eyes.     He  cites  the  case  of  a  medical  professor  who 

*  "  Traits  des  Maladies  de  I'CEeil,"  1707,  p.  2G0. 

t  "  Maladies  des  Yeux,  traduite  par  Kiester,"  Paris,  1832,  tome  ii,  p. 
215. 

X  "  Trait6  de  rOpLthalmie,"  etc.,  Paris,  1837. 

*  Dr.  William  KitcLner,  "  Economy  of  the  Eyes,"  1824. 

^  Piorry  (1850),  "Traite  de  Medecine  pratique,"  tome  vii. 


INTRODUCTION.  7 

habitually  suffered  from  migraine  after  reading  his 
lectures  written  in  very  fine  characters,  and  who  was 
free  from  the  affection  when  he  did  not  read  the  lect- 
ures. He  also  mentions  the  case  of  another  physi- 
cian who  suffered  severely  from  the  same  affection 
uniformly  after  several  attempts  to  use  glasses  not 
adapted  to  his  eyes.  Piorry  made  no  practical  appli- 
cation of  these  views. 

These  few  examples  will  serve  to  illustrate  the  ex- 
tent to  which  the  eyes  were  supposed  to  affect  con- 
tiguous or  more  remote  parts,  up  to  the  era  when,  by 
the  discovery  of  the  ophthalmoscope  by  Helmholtz,  by 
the  recognition  of  the  role  played  by  the  ocular  mus- 
cles in  inducing  fatigue  about  the  eyes,  a  subject  espe- 
cially elucidated  by  Von  Graefe,  and  by  the  discovery 
of  hypermetropia  by  Donders,  the  knowledge  of  the 
causes  and  treatment  of  asthenopia  was  infinitely  pro- 
moted. 

Notwithstanding  these  great  advances,  the  phe- 
nomena of  asthenopia  continued  to  be  stated  in  much 
the  same  order  as  before. 

Graefe  and  Donders  enumerate  the  symptoms  sub- 
stantially as  they  are  given  above,  and  Stellwag* 
concludes  his  excellent  description  of  accommodative 
asthenopia  as  follows : 

"If  the  work  is  continued"  (after  the  sense  of  ex- 
haustion has  commenced),  "these  feelings"  (confusion 
of  vision  and  swimming  of  objects  before  the  eyes, 
with  a  feeling  of  pressure,  fullness,  and  tension  in  the 
forehead)  "  soon  increase  to  actual  pain  in  and  over 

*  Stellwag,  first  American  edition,  1868,  p.  622. 


8  INTRODUCTION. 

the  eyes  and  are  soon  accompanied  by  a  very  painful 
feeling  of  dazzling  ;  finally  headache,  dizziness,  uni- 
versal malaise,  and  even  nausea  occur." 

Beyond  question,  however,  the  most  important 
recognition  of  the  fact  that  distant  pain  might  be 
induced  by  straining  the  eyes  was  by  Anstie,*  who  as- 
serted that  "functional  abuse  of  the  eyes"  is  a  power- 
ful source  of  irritation  tending  to  induce  neuralgia. 

He  also  says  that  hyperopic  sewing-girls  are  spe- 
cially liable  to  that  affection,  and  relates  that  he  him- 
self was  relieved  from  neuralgia  by  desisting  from  the 
use  of  his  eyes  in  reading. 

I^otwithstanding  these  assertions,  Anstie  seems  to 
have  made  no  practical  application  of  the  important 
facts  thus  enunciated,  and  even  seems  to  regard  the 
conditions  as  accidental  and  factitious. 

Possibly  a  greater  familiarity  with  the  defects 
which  are  known  to  be  influential  in  the  jDroduction  of 
asthenopia  would  have  encouraged  this  learned  author 
to  make  some  practical  application  of  a  principle 
which  he  seems  to  have  very  imperfectly  recognized. 

Thus  far,  then,  there  had  been  recognized  certain 
isolated  facts  concerning  irritations  arising  from  disad- 
vantageous use  of  the  eyes,  in  relation  to  parts  some- 
what removed  from  them. 

No  general  principle  of  sympathetic  or  reflex  irri- 
tation had,  however,  been  formulated,,  and  the  first 
printed  announcements  of  the  existence  of  such  a 
principle  was  made  by  myself,  in  a  paper  presented  to 
the  Albany  Institute  in  the  early  part  of  1876,  and 
*  "  Neuralgia,"  D.  Appleton  &  Co.,  New  York,  1872. 


INTRODUCTION.  9 

soon  after  in  a  paper  read  before  the  Academy  of 
Medicine  in  New  York,  June  15tli  of  the  same  year. 
The  doctrine  had,  however,  been  publicly  taught  by 
me  in  lectures  in  the  Albany  Medical  College  two  years 
previously  to  the  reading  of  these  papers,  and  several 
cases  in  which  chorea  and  other  nervous  diseases  were 
in  relations  of  effects  of  ocular  disturbances  had  been 
exhibited  to  my  classes.  Several  papers  relating  to 
this  subject  have  been  given  to  the  public  by  myself 
from  time  to  time  in  which  the  doctrine  has  been 
somewhat  more  fully  developed.* 

A  few  writers  have,  since  my  first  publications  on 
this  subject,  recognized  certain  facts  relating  to  it,  but 
it  can  not  be  said  that  any  contribution  of  considerable 
importance  has  been  added  to  the  literature  beyond 
what  has  been  stated. 

If  it  is  remembered  that  pain  over  the  eyes,  and 
even  general  headache,  with  feelings  of  general  malaise, 
have  been  long  recognized  as  among  the  occasional 

♦  See  "  Transactions  of  the  Albany  Institnte,  1874-1876  " ;  "  Chorea," 
"  Transactions  of  the  New  York  Academy  of  Medicine,"  1876 ;  "  Refrac- 
tive Lesions  and  Functional  Nervous  Diseases,"  "New  York  Medical 
Record,"  September,  1876 ;  "  Light  in  its  Relation  to  Disease,"  "  New 
York  Medical  Journal,"  June,  1877;  "  Clinical  Notes  of  Cases  of  Neu- 
ralgia and  Troubles  of  the  Accommodation  of  the  Eye,"  "New  York 
Medical  Record,"  October,  1877 ;  "  Relations  between  Corneal  Diseases 
and  Refractive  Lesions  of  the  Eye,"  International  Medical  Congress, 
Philadelphia,  1877 ;  "  Enucleation  of  an  Eyeball,  followed  by  Immediate 
Relief  in  a  Case  of  Diabetes  Insipidus,"  "  Transactions  of  the  American 
Ophthalmological  Society,"  1878 ;  "  Two  Cases  of  Enucleation  of  the 
Eyeball,"  "  Alienist  and  Neurologist,"  January,  1880 ;  "  Ocular  Muscular 
Defects  and  Nervous  Troubles,"  "Transactions  of  the  New  York  State 
Medical  Society,  1880;  "  Oculo-Neural  Reflex  Irritation,"  International 
Medical  Congress,  London,  1881 ;  etc. 


10  INTRODUCTION. 

symptoms  of  astlienopia,  it  will  be  understood  that,  in 
the  treatment  of  their  asthenopia  patients,  oculists  have 
from  time  to  time  casually  relieved  these  more  general 
symptoms  while  pursuing  the  rational  measures  of 
treatment  for  asthenopia.  Such  relief,  incidental  so 
far  as  the  design  in  treatment  was  concerned,  did  not, 
in  the  minds  of  oculists  suggest  the  principle  that  for 
such  general  symptoms  not  attendant  upon  asthenopia, 
the  condition  of  the  eyes  should  be  examined,  and  per- 
haps treated.  Thus,  while  Graefe  recognized  headache 
as  one  of  the  occasional  symptoms  of  asthenopia,  he  did 
not  suggest  that  persons  subject  to  chronic  cephalalgia 
should  consult  an  oculist. 

If  the  doctrines  taught  in  the  following  pages 
should  be  accepted  by  the  medical  profession,  doubt- 
less many  oculists  might  be  able  to  recall  relief  to 
headaches  as  incidental  to  treatment  of  asthenopia. 
It  would  not  be  surprising  even  if  the  recollection  of 
such  an  occurrence  should  induce  in  the  mind  of  the 
practitioner  the  belief  that  he  was  then  acting  upon 
the  principle  here  developed, 

A  careful  and  extensive  search  in  the  literature  of 
ophthalmology  and  of  general  medicine  has  not  en- 
abled the  writer  to  find  any  mention  of  the  principle 
that  irritations  arising  from  ocular  adjustments  may 
act  as  reflex  causes,  inducing  nervous  troubles  in  dis- 
tant parts,  except  in  the  vague  manner  already  men- 
tioned, prior  to  his  own  announcement  of  it. 

Should  the  facts  presented  in  this  memoir  appear 
to  differ  so  essentially  from  the  experience  of  medical 
practitioners  generally  as  to  seem   to   belong  to  the 


INTRODUCTION.  H 

marvelous,  it  can  be  said  that  they  are  all  capable 
of  being  fully  substantiated. 

The  author  refers  with  pleasure  to  the  several  well- 
known  medical  gentlemen  whose  names  appear  in  con- 
nection with  some  of  the  most  typical  cases  here 
reported.  He  is  sure  that  in  every  instance  these 
physicians  will  affirm  that  these  cases  have  been  not 
only  not  exaggerated,  but  in  every  instance  under- 
stated. 

Surely  we  are  not  to  hope  for  a  specific  against  all 
neuroses.  Our  greatest  advance  must  be  in  the  recog- 
nition of  some  new  classes  of  causative  influences, 
and  the  means  of  combating  those  influences.  If  the 
author  has  presented  to  his  profession  one  such  new 
class  of  influences  which  shall  be  found  of  signal  im- 
portance, his  purpose  will  have  been  fully  accom- 
plished. 


FUNCTIONAL 
NERVOUS  AFFECTIONS. 


In  the  study  of  nervous  affections,  the  division  of 
such  disorders  into  functional  and  organic  has  long 
been  recognized ;  and  while  these  groups  touch  and 
mingle,  so  that  no  accurate  boundary  can  be  drawn 
between  them,  the  division  is  nevertheless  practical 
and  necessary. 

In  the  first  group  is  found  an  extensive  array  of 
disturbances,  characterized  by  diminution  or  increase 
of  sensory  or  of  motile  power,  or  by  a  variety  of  other 
phenomena  in  which  we  find  no  evidence  of  an  organic 
change,  either  of  the  nerve  affected  or  of  any  portion 
of  the  central  nervous  system. 

In  the  second  group,  distinct  anatomical  lesions 
are  found,  which  may  account  for  some  or  all  of  the 
peculiar  manifestations. 

There  are  certain  obvious  advantages  in  the  study 
of  the  etiology  of  the  first  group.  In  case  of  struct- 
ural degeneration  of  a  portion  of  the  nervous  organiza- 
tion, should  the  true  cause  of  the  disturbance  be  found 
and  removed,  the  degenerated  structure  may  not  re- 


14  FUNCTIONAL  NERVOUS  AFFECTIONS. 

sume  its  normal  function  or  physical  condition,  and 
the  symptoms  may  continue. 

On  the  other  hand,  if,  in  case  of  functional  nervous 
disorder,  the  cause  be  removed,  a  reasonable  hope  may 
be  entertained  that  the  normal  state  may  be  resumed  ; 
and  if  the  removal  of  a  hypothetical  cause  is  system- 
atically followed  by  a  cessation  of  the  nervous  dis- 
turbances, we  have  evidence  of  value  that  the  hypo- 
thetical is  the  actual  cause. 

Two  classes  of  influences  are  recognized  as  causes 
of  functional  nervous  disorders,  the  more  remote  or 
predisposing  causes  and  those  which  are  immediate. 
The  former,  while  frequently  of  insufficient  intensity 
to  originate  neuroses,  may,  when  the  nervous  disturb- 
ance has  been  once  instituted,  be  sufficient  to  x^erpetu- 
ate  it  for  an  indefinite  time.  Immediate  causes  are 
perhai')S  rarely  of  a  nature  to  induce  long-continued 
nervous  disorder,  and  in  many  instances,  in  which  an 
occasion  of  disturbance  may  seem  to  be  clearly  indi- 
cated by  the  history  of  the  affection,  the  influence  of 
the  supposed  cause  may  long  have  passed  away,  while 
a  pre-existing  cause  may  be  continuing  the  disorder. 
This  fact  can  not  be  too  clearly  recognized  in  the  study 
of  this  class  of  affections. 

It  may,  for  instance,  be  of  little  practical  impor- 
tance that  a  child  first  manifested  symptoms  of  chorea 
while  under  the  influence  of  fright.  The  evil  has  been 
accomplished,  and  the  event  can  not  be  recalled,  nor 
can  such  an  influence  be  regarded  as  permanent  or  of 
long  continuance.  Hence,  if  the  child  continues  to 
manifest  the  symptoms  of  chorea,  it  is  reasonable  to 


NEUEOPATHIC  PREDISPOSITION.  15 

search  for  an  underlying  cause  whicli  is  permanent  or 
continuous.  Otherwise,  it  would  be  necessary  to  as- 
sume that,  as  a  result  of  the  immediate  cause,  some 
radical  disarrangement  of  nervous  action  originated 
which  perx^etuates  itself. 

^uch  radical  disarrangement  has  not  been  demon- 
strated, nor  is  its  existence  at  all  probable.  The  hy- 
pothesis, therefore,  that  there  is  an  underlying  cause 
of  disturbance  becomes  stronger  in  proportion  as  the 
idea  of  a  radical  disarrangement  is  surrendered.  Such 
underlying  causes  are  fully  recognized  by  students  of 
nervous  disorders,  and  their  existence  is  so  constantly 
verified  by  the  daily  experience  of  medical  observers 
that  their  importance  can  not  be  questioned. 

Persons  in  whom  such  underlying  causes  exist  are 
said  to  possess  a  neurojpatMo  jpredlspositlon^  and  indi- 
viduals subject  to  this  unfortunate  predisposition  are 
liable,  from  trifling  immediate  causes,  to  suffer  from 
neuroses  which  manifest  themselves  in  a  great  variety 
of  ways.  Thus,  one  individual  will,  as  a  sequel  to 
almost  every  unusual  emotional  or  intellectual  excite- 
ment or  depression,  suffer  from  headache ;  another 
will,  with  atmospheric  changes  so  slight  as  to  be  little 
regarded  by  most  persons,  habitually  "take  cold." 

One  result  of  the  many  careful  observations  which 
have  been  made  respecting  this  neuropathic  predis- 
position has  been  to  demonstrate  that  in  a  very  large 
proportion  of  instances  it  is  hereditary ;  but  that  the 
hereditary  tendency  does  not  necessarily  transmit  the 
identical  form  of  neurosis,  and  that  any  one  or  more 
of  a  variety  of  kindred  affections  may  arise  as  the 


16  FUNCTIONAL  NERVOUS  AFFECTIONS. 

result  of  the  tendency.  This  important  principle  is 
illustrated  in  innumerable  instances  in  which  individ- 
uals suffering  from  a  special  form  of  nervous  disease 
are  able  to  trace  the  same  or  some  quite  different 
form  of  nervous  trouble  in  parents  or  relatives. 
Thus,  in  one  habitually  subject  to  neuralgia,  a  family 
tendency  may  be  found  to  various  neuroses,  such  as 
chorea,  epilepsy,  oft-recurring  nervous  headaches,  or 
possibly  insanity. 

Anstie,  who  has  made  special  and  extensive  inquiry 
respecting  this  tendency,  finds  that  neuralgia,  insani- 
ty, epilepsy,  paralysis,  chorea,  a  tendency  to  uncon- 
trollable alcoholic  excesses,  and  phthisis  are  among 
the  group  of  disorders  which,  through  hereditary  tend- 
ency, may  manifest  themselves  either  in  the  same 
manner  or  interchangeably. 

The  nature  of  such  predisposition  has  not  been  rec- 
ognized to  an  extent  equal  to  its  importance,  and  it 
will  be  one  of  the  objects  of  this  essay  to  point  out 
a  physiological  group  of  circumstances  which,  beyond 
a  doubt,  constitutes  a  most  important  factor  in  this 
tendency.  The  great  value  of  the  knowledge  of  this 
factor  in  the  predisposing  tendency  will  appear  when 
it  is  stated  that  this  group  of  physiological  circum- 
stances is  capable  of  such  modification  as  to  render  it 
in  most  instances  comparatively  harmless. 

Of  immediate  causes  of  neuroses,  there  is  so  great 
a  variety  that  any  attempt  at  an  enumeration  would 
be  futile.  Among  the  more  frequent  and  important, 
however,  may  be  mentioned  the  depressed  conditions 
of  the  nervous  system  after  recovery  from  exanthem- 


MODIFYING  TENDENCIES.  17 

atous  diseases,  severe  and  long-continued  mental  or 
physical  strain,  excessive  emotional  excitements,  phys- 
ical shock,  and  sudden  and  extreme  changes  of  tem- 
perature. 

The  effect  of  these  and  many  other  exciting  causes 
must,  in  the  nature  of  the  case,  be  transitory,  and, 
independently  of  some  more  permanent  influence,  can 
rarely  if  ever  account  for  long-continued  and  especial- 
ly for  intermitting  forms  of  nervous  diseases. 

Another  class  of  causes  should  be  recognized  as 
exerting  marked  influence  in  nervous  disorders.  These 
may  be  designated  '-'•  modifying  tendencies.'''' 

Among  these  may  be  mentioned  the  influence  of 
vitiated  atmosphere — the  so-called  malaria ;  the  period 
of  life ;  the  performance  of  certain  physiological  func- 
tions, especially  those  peculiar  to  females;  and  the 
nature  of  the  employment  of  the  individual.  Thus, 
one  subject  to  recurring  headaches,  while  residing  in 
a  malarial  region,  may  find  the  paroxysms  so  modi- 
fied as  to  resemble  attacks  of  malarial  fever.  The 
period  of  recurrence  of  migraine  or  of  ordinary  head- 
aches is  in  a  considerable  number  of  females  governed 
by  the  recurrence  of  certain  physiological  periods. 

It  must  be  evident  that,  whatever  may  be  the  ex- 
citing cause  of  a  neurosis,  it  must,  under  the  great 
majority  of  circumstances,  be  of  infinitely  less  conse- 
quence than  the  influence  which  leads  to  it  and  per- 
petuates it. 

The  predisposing  influence  not  only  tends  to  pro- 
long the  disorder,  but  in  a  vast  number  of  instances, 
when  a  certain  form  of  disorder  is  supposed  to  be 


18  FUNCTIONAL  NERVOUS  AFFECTIONS. 

cured,  individuals  subject  to  the  neuropathic  predis- 
position will  become  the  victims  of  some  other  nerv- 
ous disease.  Individuals  affected  by  one  form  of 
nervo'us  disorder  at  one  period  of  life  are  especially- 
liable  to  suffer  from  some  other  form  at  another  pe- 
riod. Thus,  chorea  in  most  instances  runs  its  course 
in  the  space  of  a  few  weeks,  but  the  person  who  has 
been  a  victim  of  this  affection  in  early  life  will  be 
likely  to  suffer  from  neuralgia  or  headaches,  and  some- 
times from  epilepsy,  in  later  years.  Hence,  the  pre- 
disposition is  one  which  is  a  constant  element  in  the 
organization  of  the  individual,  and  may  be  the  same 
for  different  forms  of  disorders ;  and,  moreover,  the 
cure  of  one  complaint  may  be  only  the  signal  for  the 
commencement  of  another ;  or,  more  correctly,  the 
supposed  cure  of  one  form  of  disorder  may  be  only 
a  change  in  the  manner  of  manifesting  a  permanent 
irritation. 

These  principles  being  accepted,  it  is  important  to 
inquire  whether  such  a  predisposing  cause  must  be 
general,  pervading  the  whole  organism,  thus  affecting 
the  whole  nervous  system;  or  must  it  at  least  neces- 
sarily find  its  seat  in  the  nervous  centers  ;  or  may 
it  be  entirely  local,  affecting  directly  only  a  limited 
number  of  nerves? 

To  this  question  the  answer  may  unhesitatingly  be 
given,  that  the  predisposing  or  irritating  cause  may  be 
wholly  local,  and  confined  to  any  portion  of  the  cen- 
tral or  peripheral  nervous  system. 

An  irritation  set  up  in  any  nerve  gives  rise  to  the 
greatest  variety  of   disturbances  in  any  or  all  other 


EEFLEX  lEEITATIONS.  19 

parts  of  the  organism,  however  distant.  Hence  it  is 
not  logically  necessary  to  suppose  a  universally  per- 
vading or  even  a  central  initial  irritation  in  order  to 
explain  the  neuropathic  predisposition.  The  experi- 
ments of  Sir  Charles  Bell,  of  Marshall  Hall,  and  of 
many  subsequent  observers,  have  so  clearly  proved 
this  doctrine  that  it  is  beyond  question.  Dr.  Brown- 
Sequard,  in  enumerating  some  of  the  effects  of  tick- 
ling the  sole  of  the  foot  in  a  large  number  of  sub- 
jects, speaks,  among  other  things,  of  laughter,  of 
tears,  of  jerks  of  one  or  both  limbs  of  a  side,  or  of 
all  the  limbs,  of  tremblings  and  spasms,  while  in 
some  instances  no  effect  was  manifest. 

If  it  be  admitted  that  the  neuropathic  predisposi- 
tion may  consist  of  a  local  irritation  and  not  neces- 
sarily of  some  peculiar  and  undemonstrated  general 
"modifications  of  molecular  arrangements,"  we  are 
prepared  to  inquire  whether,  inasmuch  as  this  tendency 
is  transmitted  from  parent  to  child,  the  evil  may  not 
consist  of  some  peculiarity  of  anatomical  structure, 
or  of  physiological  adaptations,  which  is  inconsistent 
with  the  most  regular  and  easy  performance  of  the 
function  of  a  part  or  parts  ? 

This  would  unquestionably  be  a  reasonable  hypoth- 
esis, and  we  are  at  once  led  to  inquire  whether  mechan- 
ical or  physiological  peculiarities  of  this  sort  are  likely 
to  occur  in  a  sufficiently  uniform  manner  to  enable 
us  to  classify  them  and  to  determine  to  which,  if  to 
any  class,  any  very  considerable  number  of  irrita- 
tions may  be  attributed ;  or  whether,  in  other  words, 
certain  classes   of  mechanical  peculiarities  are  more 


20  FUNCTIONAL  NERVOUS  AFFECTIONS. 

than  usually  liable  to   become  factors  of  physiologi- 
cal disturbance. 

Manifestly,  any  hypothesis  which  assumes  this 
must,  to  be  sustained,  be  based  upon  many  and  long- 
continued  observations  conducted  in  a  spirit  of  judi- 
cial independence,  and  free  from  all  such  bias  as 
might  result  from  occasional  and  exceptional  experi- 
ences. 

It  is  believed  that  the  views  advanced  in  this  es- 
say are  thus  based,  and  that  a  Just  regard  for  the 
experiences  and  teachings  of  all  who  have  contributed 
to  this  important  subject  has  been  observed. 

The  conclusions  here  announced  are  based  upon 
observations  in  twenty-six  hundred  and  ninety- two 
cases  of  nervous  diseases  in  private  practice  and  of 
a  considerable  number  of  cases  in  public  institu- 
tions,* which  have  been  made  with  as  much  care  and 
precision  as  the  exacting  demands  of  an  active  pro- 
fessional life  would  permit. 

That  in  the  course  of  these  observations  individ- 
ual cases  have  failed  to  receive  due  attention  is  doubt- 
less true;  but  that  in  the  general  results  of  this  in- 
vestigation the  conclusions  reached  are  accurate,  the 
author  believes  that  he  can  affirm  without  presump- 
tion. 

In  the  confirmed  belief  that  the  neuropathic  pre- 
disposition must  of  necessity  be  the  manifestation  of 
many  structural  peculiarities  located  in  various  parts 
of  the  organism,  any  of  which  may  descend  from 
parent  to  child,  but  which  do  not  necessarily  so  de- 
*  Up  to  the  time  of  writing,  in  1883. 


GENERAL  PROPOSITION.  21 

scend,  and  fully  appreciating  the  influence  of  sucli 
immediate  and  modifying  causes  as  have  been  already 
mentioned,  the  conclusion  arrived  at  in  this  investi- 
gation may  be  stated  in  the  following  proposition: 

Difficulties  attending  the  functions  of  accommo- 
dating and  of  adjusting  the  eyes  in  the  act  of  vision, 
or  irritations  arising  from  the  nerves  involved  in 
these  processes,  are  among  the  most  prolific  sources 
of  nervous  disturbances,  and  more  frequently  than 
other  conditions  constitute  a  neuropathic  tendency. 

A  doctrine  so  much  at  variance  with  the  ordinary 
beliefs  must,  of  necessity,  excite  suspicion  that  the 
proposition  has  been  based  upon  insufficient  data,  or 
that  observations  have  been  imperfectly  made.  That 
neither  of  these  suspicions  is  correct  it  is  hoped  may 
be  demonstrated  to  the  entire  satisfaction  of  reason- 
able inquirers. 

If  to  the  reader  the  proposition  appears  extreme, 
and  tending,  at  best,  to  the  recognition  of  a  single 
class  of  causes  to  the  exclusion  of  others,  he  is  cau- 
tioned to  observe  that  the  proposition  fully  recog- 
nizes any  and  all  causes  of  nervous  irritation,  and 
that  the  influences  indicated  by  it  are  held  to  be 
pre-eminent,  but  not  exclusive  permanent  causes. 

If,  in  this  discussion,  greater  importance  will  be 
conceded  to  these  than  to  other  influences,  it  will  be 
from  no  unmindfulness  of  the  possibility  of  other 
conditions  acting  as  irritating  influences,  or  that  cer- 
tain known  or  unknown  agencies  may  give  character 
to  the  results  of  irritation  arising  from  the  influences 
here  specfied. 


22  FUNCTIONAL  NERVOUS  AFFECTIONS. 

Let  it  be  remembered  that  it  has  been  universally 
conceded  that  the  nature  of  the  neuropathic  tendency- 
is  unknown. 

If  one  pre-eminently  important  element  of  that 
tendency  is  here  demonstrated,  it  is  not  to  be  re- 
jected because  it  may  not  include  the  whole. 

In  the  explanation  of  the  etiology  and  treatment 
of  disease,  neither  settled  theories  nor  novel  doctrines 
can  be  proved,  except  as  they  are  confirmed  by  un- 
doubted facts.  Nor  can  isolated  facts,  nor  facts  di- 
vested of  their  natural  environments,  be  accepted  as 
valid  evidence  in  support  of  theories,  old  or  new. 
The  facts  must  be  uniform,  occurring  so  regularly  as 
sequences  as  to  demonstrate  that  they  are  conse- 
quences. Unless  the  skilled  observer  is  able  to  pre- 
dict with  a  reasonable  degree  of  accuracy  the  result 
of  certain  combinations  of  circumstances,  such  results 
must  be  considered  accidental. 

Before  presenting  facts  upon  which  this  proposi- 
tion is  based,  it  will  be  well  to  inquire  whether  it  is 
reasonable  to  suppose  that  irritation  sufficient  to  cause 
or  perpetuate  a  long-continued  series  of  disordered 
nervous  phenomena  can  arise  from  the  performance  of 
the  functions  of  the  eyes,  and,  if  so,  what  is  the  origin 
of  the  supposed  irritation? 

In  order  to  arrive  at  a  fair  understanding  of  this 
subject,  it  will  be  in  place  to  review  some  points  in 
the  theory  of  adjustments  of  the  eyes  in  the  act  of 
vision,  which,  although  well  known  to  oculists,  may 
be  less  familiar  to  those  not  specially  engaged  in  ex- 
amining the  defects  of  vision. 


EEFRACTIVE  MEDIA  OF  THE  EYE. 


23 


When  rays  of  light  fall  upon  the  transparent  sur- 
face of  a  healthy  eye,  they  jDass  beyond  the  surface, 
through  the  pupil,  and  through  the  transparent  media 
to  the  retina.  If  a  distinct  image  is  formed,  the  rays 
must  unite  at  the  focus  of  the  eye,  which  is  the  reti- 
na. To  this  end,  the  rays  are  refracted  as  they  pass 
through  the  media.  In  the  normal  eye  the  refractive 
power  is  such  that  parallel  rays,  rays  from  objects  at 
infinite  distance,  unite  precisely  at  the  retina.  If  ob- 
jects are  to  be  clearly  perceived  at  different  distances, 
it  is  obvious  that  some  provision  must  exist  for  chang- 
ing the  focus  of  the  eye ;  for,  while  rays  from  a  dis- 
tant object  are  parallel,  those  from  near  objects  di- 
verge as  they  pro- 
ceed from  the  ob- 
ject to  the  eye. 
These  diverging 
rays  must  be  more 
strongly  refracted, 
in  order  to  meet 
at  the  retina,  than 
parallel  rays.  In 
the  refracting  me- 
dia of  the  eye  there 
are  different  fac- 
tors ;  they  are  the 
anterior  surface  of 
the  cornea,  the  an- 
terior surface  of  the  lens,  and  the  anterior  surface  of 
the  vitreous  humor.     The  relations  of  these  parts  and 

the  retina  may  be  briefly  described  as  follows : 
3 


Fig.  1. — Diagrammatic  section  of  the  eye.  s, 
sclera  ;  c.  cornea  ;  i,  iris  ;  ch,  choroid ;  r,  re- 
tina ;  ah,  aqueous  humor ;  cl,  crystalline  lens  ; 
v7i,  vitreous  humor  ;  cap,  capsule ;  on,  optic 
nerve ;  ml,  macula  lutea. 


24  FUNCTIONAL  NERVOUS  AFFECTIONS. 

The  tough  protective  shell  of  the  eye,  the  sclera, 
maintains  the  form  and  holds  in  place  the  transparent 
humors  which  fill  its  space.  At  the  front  of  the  eye- 
ball this  hard  coat  is  so  modified  in  structure  as  to 
constitute  the  transparent  cornea.  Behind  this  trans- 
parent substance  is  the  curtain,  the  ii^is,  near  the  cen- 
ter of  which  is  an  opening,  the  pupil.  The  crystalline 
lens  lies  behind  the  pupil,  and  the  considerable  space 
behind  the  lens  and  in  front  of  the  retina  is  occupied 
by  the  vitreous  humor.  Light  from  a  luminous  object 
passes  through  the  cornea  and  pupillary  opening,  then 
through  the  crystalline  lens,  and  thence  to  the  retina. 

Now,  in  order  to  maintain  such  a  condition  of  these 
refracting  media  that  objects  at  different  distances  may 
be  seen  accurately,  there  must  be  some  change  in  the 
relative  refracting  power ;  in  other  words,  the  eye  must 
be  capable  of  altering  its  focus. 

In  the  well-known  optical  instrument,  the  opera- 
glass,  the  focus  is  adjusted  by  turning  a  screw,  so  that 
the  lenses  approach  or  recede  from  each  other  ;  in  the 
eye  the  change  is  produced  by  alterations  in  the  con- 
vexity of  the  crystalline  lens  through  the  action  of  the 
ciliary  muscle  upon  it.  The  lens  is  held  in  its  relation 
to  the  muscle  by  its  delicate  envelope,  the  capsule,  and 
the  muscle  is  capable  of  contraction  under  the  influ- 
ence of  the  will,  in  which  case  the  opening  becomes 
smaller.  When  this  happens,  the  lens,  by  virtue  of 
its  elasticity,  becomes  more  convex,  and  its  refracting 
power  is  increased. 

When,  on  the  contrary,  the  muscle  returns  to  a 
state  of  rest,  the  inner  border  approaches  the  outer 


FUNCTION  OF  ACCOMMODATION.  35 

border,  the  opening  is  enlarged,  and  the  lens,  com- 
pressed by  the  greater  tension  of  the  capsule,  becomes 
less  convex.  In  the  former  case  it  is  said  to  be  accom- 
modated for  near  points,  in  the  latter  for  distaijce ; 
and  the  power  of  thus  changing  the  form  of  the  lens, 
and  consequently  the  focus  of  the  eye,  is  called  the 
function  of  accommodation. 

This  function  of  accommodation  is  always  brought 
into  use  when  the  eye  is  directed  to  points  at  different 
distances  from  it. 

If  the  eye  is  of  the  most  perfect  form  and  the  media 
in  the  most  perfect  condition,  this  function  is  per- 
formed with  ease,  the  ciliary  muscle  having  abundant 
strength  to  execute  the  changes  to  any  reasonable  ex- 
tent without  undue  fatigue. 

But  it  so  happens  that  this  function  is  not  always 
performed  in  this  easy  and  regular  manner.  Eyes  are 
not  all  constituted  in  the  most  perfect  fashion,  nor 
does  the  crystalline  lens  always  maintain  a  uniform 
degree  of  elasticity ;  hence,  not  infrequently  the  ciliary 
muscle  is  called  upon  to  perform  an  amount  of  labor 
quite  exhausting ;  or  it  may  be,  on  account  of  certain 
irregularities  in  the  demands  upon  it,  the  muscle  is 
subjected  to  a  perplexity  or  fret  from  which  it  is  easily 
exhausted. 

Some  of  the  defects  in  the  form  of  the  eye  which 
have  an  influence  upon  the  accommodation  may  be 
easily  comprehended  by  comparing  certain  well-under- 
stood anomalies  with  the  ideal,  or,  as  it  is  called,  the 
emmetropic  eye. 

In  the  emmetropic  eye  parallel  rays  are  so  refract- 


26  FUNCTIONAL  NERVOUS  AFFECTIONS. 

ed  that,  without  an  effort  on  the  part  of  the  muscle 
of  accommodation,  they  meet  at  the  back  of  the  eye. 

This  normal  eye  is,  then,  in  a  passive  condition  or 
state  of  complete  rest  when  looking  at  a  distant  ob 
ject;  but  as  the  object  approaches  within  what  is 
called  "finite"  distance,  which  in  ophthalmology  is 
within  six  metres,  the  act  of  accommodation  must  be 
exercised.  This  in  the  ideal  eye  demands  a  moderate 
muscular  exertion. 

But  in  the  hypermetropic  eye,  which  is  a  short  eye,* 
the  refractive  media  are  not  sufficient  to  bring  parallel 
rays  to  a  focus  at  the  retina.  In  such  an  eye  the  rays, 
if  permitted  to  pass  beyond  the  retina,  would  unite  in 
a  focus  behind  it.  In  such  an  eye,  clear  vision  can 
only  be  obtained  by  giving  to  the  rays  a  greater  re- 
fraction than  occurs  when  the  eye  is  passive.  Such 
additional  refraction  might,  if  no  other  means  existed, 
be  supplied  by  a  convex  lens,  but  ordinarily  the  ob- 
ject is  attained  by  causing  the  crystalline  lens  to 
assume  greater  convexity — in  other  words,  by  the  act 
of  accommodation. 

In  the  hypermetropic  eye,  then,  accommodation 
must  be  exercised  even  in  looking  at  the  most  dis- 
tant object ;  and  as  long  as  the  eye  continues  to  see 
clearly  at  any  distance,  this  exertion  must  be  contin- 
ued. If  the  object  to  be  seen  is  near  the  eye,  the  effort 
must  be  excessive.  Hence,  such  an  eye  is  never  at 
rest  when  seeing  at  all,  and  is  performing  excessive 
labor  when  looking  at  near  points.  In  a  certain  pro- 
portion of  hypermetropic  eyes  the  ciliary  muscle,  even 

*  The  "  short  eye  "  must  not  be  confounded  with  "  near-sight." 


ERRORS  OF  REFRACTION.  27 

by  the  highest  exercise  of  its  power,  is  unable  to  ac- 
complish the  task  of  accommodation,  and  such  eyes 
obtain  no  clearly  defined  images  except  by  artificial 
aid. 

The  myopic  eye,  on  the  contrary,  is  too  long,  and 
parallel  rays  refracted  in  the  same  manner  as  in  the 
emmetroi^ic  eye  cross  before  reaching  the  retina.  Cir- 
cles .of  diffusion  take  the  place  of  distinct  images  when 
distant  objects  are  to  be  viewed,  and,  except  for  ob- 
jects brought  within  the  focus  of  the  eye,  vision  is 
materially  impaired. 

Again,  the  refracting  surfaces  of  the  eye  may  be 
irregular  in  their  curvature,  in  which  case  a  pencil 
of  rays  will  not  be  brought  to  a  point.  This  irregu- 
larity is  often  found  in  the  cornea.  The  curvature 
in  one  meridian  may  be  greater  or  less  than  in  that 
at  right  angles  to  it.  In  this  case  we  have  a  con- 
dition called  astigmatism. 

These  errors  are  called  errors  of  refraction ;  and 
there  are  other  defects  which  relate  more  especially 
to  the  act  of  accommodation.  Thus,  after  the  age  of 
fifty,  the  crystalline  lens  in  the  best-formed  eyes  has 
lost  so  much  of  its  elasticity  that  the  act  of  accom- 
modation for  near  objects  becomes  quite  difficult,  and 
this  difficulty  increases  year  by  year,  until  at  the  age 
of  seventy  the  function  of  accommodation  is  practi- 
cally lost.  Debility  or  paralysis  of  the  ciliary  muscles 
may  also  cause  difficult  accommodation. 

To  illustrate  the  effect  of  these  and  other  defective 
conditions  of  refraction  and  accommodation,  a  single 
condition  may  be  selected  as  an  example. 


28  FUNCTIONAl.  NERVOUS  AFFECTIONS. 

The  effects  of  hypermetropia  can  perhaps  be  more 
easily  understood  than  the  effects  of  other  errors. 
For  that  reason,  and  not  because  of  its  greater  im- 
portance compared  with  other  anomalies,  these  effects 
are  more  fully  discussed  here.  An  examination  of 
the  results  of  this  condition  must  serve  to  illustrate 
the  disadvantages  of  the  other  anomalous  conditions, 
notwithstanding  the  fact  that  the  disturbances  from 
the  different  conditions  arise  in  various  ways. 

As  it  has  been  shown,  the  hypermetropic  eye  is 
short,  and  rays  of  light  do  not  come  to  a  focus  at  the 
retina  without  an  effort  of  accommodation.  If  the 
degree  of  hypermetropia  is  moderate,  and  the  ciliary 
muscle  is  vigorous,  objects  at  a  distance  (in  the  ex- 
amination of  visual  conditions  a  distance  of  about  six 
metres  or  more  is  called  infinite  distance)  may  be 
seen  clearly  without  any  percej)tible  strain  upon  the 
eye.  If,  however,  the  eye  is  directed  for  consider- 
able periods  of  time  to  near  objects,  as  in  reading, 
the  muscle  is  overtasked.  All  know  how  a  light 
weight  seems  to  grow  heavy  as  one  holds  it  in  the 
hand  while  the  arm  is  extended.  In  the  same  man- 
ner the  continued  and  unnatural  tension  of  the  ciliary 
muscle  of  the  far-sighted  eye  may  become  at  length 
a  source  of  much  weariness,  and  it  is  also  seen  that 
while  the  normal  eye  is  at  rest  when  accommodated 
for  distance  and  only  slightly  exerted  when  accom- 
modated for  near  points,  the  hypermetropic  eye  is 
never  at  rest  except  when  closed.  But  a  condition 
of  much  more  importance  than  the  simple  continued 
strain  of  muscle   is  found  in  hypermetropic  vision. 


BINOCULAE  VISION.  29 

When  tlie  two  eyes  are  fixed  on  an  object,  the  image 
of  the  point  fixed  is  at  the  yellow  spot  in  the  retina, 
and  lines  drawTi  from  the  yellow  spot  of  the  retina 
of  each  eye  through  the  center  of  the  pupil  would 
meet  at  the  point  fixed.  If  the  eyes  gaze  at  an  ob- 
ject at  the  horizon,  these  visual  lines  will  be  practi- 
cally parallel;  but  if  their  view  is  fixed  upon  a  near 
object,  these  lines  are  converged.  The  converging  of 
the  eyes  is  seen  when  one  looks  at  a  i)encil  held  a 
few  inches  in  front  of  the  face.  This  convergence  is 
effected  by  long,  straight  muscles  located  in  the  orbit 
and  attached  to  the  outer  shell  of  the  eye.  There 
are  several  of  these  long  muscles,  but  for  our  imme- 
diate purpose  only  two  belonging  to  each  eye  may 
be  mentioned :  the  external  rectus,  or  straight  muscle, 
which  tends  to  keep  the  visual  axes  removed  from 
each  other  ;  and  the  internal  rectus,  which  tends  to 
converge  these  axis.  If  the  lines  converge  exactly  in 
proportion  to  the  proximity  of  the  object,  single  vis- 
ion is  obtained  wdth  the  two  eyes.  This  associated 
or  binocular  vision  is  essential  to  exact  notions  of  the 
position  of  objects  in  space,  and,  if  not  maintained, 
much  confusion  of  impressions  results. 

It  will  at  once  be  seen  that  the  degree  of  accom- 
modation of  the  eyes  singly,  and  of  the  convergence 
of  the  optic  axes,  must  be  in  harmony.  For  if  the 
accommodation  is  fixed  for  one  point  while  the  con- 
vergence is  for  a  point  of  greater  or  less  proximity, 
there  must  result  an  absence  of  perfect  definition,  or 
the  presence  of  double  images.  Hence  the  effort  of 
the  ciliary  muscle  in  accommodating,  and  of  the  recti 


30  FUNCTIONAL  NERVOUS  AFFECTIONS. 

muscles  in  convergence,  must  be  not  only  simulta- 
neous, but  in  precise  proportion  to  each,  other.  This 
being  the  case,  a  pair  of  normal  eyes,  accommodated 
for  a  given  distance,  will  converge  for  the  same  dis- 
tance. These  muscular  efforts  are  directed  and  regu- 
lated by  nervous  impulse,  and  in  this  case  the  im- 
pulse is  exactly  proportioned.  Reverting  now  to  the 
hypermetropic  eye,  it  will  be  seen  that  a  greater 
nervous  impulse  and  more  active  muscular  contrac- 
tion must  occur  in  accommodation  than  in  the  nor- 
mal eye.  Let  it  be  supposed  that  the  muscular  ef- 
fort of  accommodation  for  a  point  one  metre  distant 
for  a  given  hyperopic  eye  is  equal  to  the  effort  in  the 
normal  eye  for  a  point  situated  at  half  that  distance  ; 
then  if  the  effort  at  convergence  equals  the  effort  at 
accommodation,  and  the  eye  is  focused  for  a  point 
one  metre  distant,  the  axes  of  the  two  eyes  will  meet 
at  a  point  not  so  far  removed,  and  the  eyes  are  not 
in  their  axes  adjusted  for  the  point  for  which  they 
are  individually  focused,  and  confusion  results. 

In  such  a  case  continual  compromising  adjustments 
must  be  made  and  great  nervous  perplexity  and  dis- 
appointed nervous  action  must  occur,  for  no  sooner 
is  one  part  of  the  adjustment  corrected  than  the 
other  is  wrong.  It  is  to  this  nervous  perplexity, 
more  than  to  the  actual  strain  of  muscle,  that  the 
weariness  and  pain  characteristic  of  hypermetropia  are 
due. 

The  principle  just  stated  may  be  illustrated  by 
the  experience  of  young  persons  who,  having  normal 
eyes,   attempt  to  use  strong  magnifying    spectacles. 


PERPLEXITY  FEOM  ASSOCIATED  MOVEMENTS.     31 

At  first  a  sense  of  slight  inconvenience  is  felt ;  but, 
if  the  attempt  be  continued  for  a  considerable  time, 
vertigo,  nausea,  and  vomiting  may  result.  This  re- 
sult does  not  pccur  if  one  of  the  eyes  is  closed. 
Hence,  the  disturbance  is  in  the  confusion  arising 
from  efforts  at  perfect  binocular  vision.  But  pre- 
cisely this  confusion  of  effort  exists  in  the  hyper- 
metropic person,  and  if  the  continuance  of  such  a 
course  of  perplexity  for  a  few  minutes  or  hours  will 
result  in  so  serious  nervous  disturbance  as  is  shown 
in  the  illustration,  is  it  not  reasonable  to  suppose 
that  a  similar  confusion  of  effort  continued  through 
many  years  may  constitute  a  permanent  source  of 
nervous  irritation  ?  Similar  i)erplexity  results  when 
either  the  internal  or  external  recti  or  other  long 
muscles  are  insufficient  to  the  performance  of  their 
functions  by  the  normal  nervous  impulse.  A  difficult 
and  more  complicated  perx)lexity  arises  in  case  of  as- 
tigmatism, and  still  other  nervous  confusion  is  the 
result  of  myopia.  Hence  all  these  abnormal  states, 
whether  from  defects  in  the  form  of  the  eyes,  or  in  the 
motor  apparatus  involved  in  associated  movements, 
may  give  rise  to  nervous  perplexity  and  irritation. 
But  it  has  been  shown  that  the  effects  of  such  per- 
plexity or  irritation  in  one  part  may  be  experienced 
in  a  distant  part,  and  this  principle  is  illustrated  in 
the  case  of  the  young  person  who  may  induce 
vomiting  by  using  magnifying  spectacles. 

However  reasonable  such  a  theory  may  appear,  it 
can  not  be  accepted  as  of  practical  value  until  it  is 
shown  that  practical  results  may  be  deduced  from  its 


32  FUNCTIONAL  NERVOUS  AFFECTIONS. 

application.  I  shall  attempt  to  show  that  such  results 
may  follow  with  a  surprising  uniformity  —  first,  by 
citing  a  single  instance  illustrating  the  effect  of  cor- 
recting each  of  the  more  commonly  recognized  defects 
of  refraction  and  association ;  second,  by  consider- 
ing at  greater  length  several  of  the  more  familiar 
conditions  of  nervous  disturbance ;  and  third,  by  at- 
tempting to  show  the  results  of  such  corrections  in 
a  given  number  of  consecutive  nervous  disorders  of 
serious  nature. 

The  first  observation  is  the  case  of  a  lad  aged 
seven  years,  whose  mother  brought  him  for  treatment 
of  the  eyes  in  1873.  The  immediate  reason  for  the 
consultation  was  pain  experienced  in  and  above  the 
eyes.  He  was  nervous,  suffering  severely  from  chorea, 
from  which  he  had  not  been  free  for  two  years.  He 
was  weak,  had  no  inclination  for  the  amusements  of 
childhood,  and  was  often  ill  in  various  ways.  He  was 
found  to  have  hypermetropia  in  high  degree.  Appro- 
priate glasses  were  directed,  which  greatly  pleased 
him.  Recovery  from  his  nervous  troubles  commenced 
at  once.  The  change  was  rapid  and  remarkable.  The 
lad  continued  to  gain  strength,  and  was,  within  a  few 
weeks,  in  all  respects  in  better  health  than  ever  he 
had  been  before.  Although  ten  years  have  passed, 
there  has  been  no  return  of  nervous  troubles. 

A  lady,  aged  twenty-one,  had  suffered  so  greatly 
from  facial  neuralgia  during  many  years  that,  among 
other  radical  measures  for  relief,  she  had  submitted, 
by  medical  advice,  to  the  extraction  of  all  her  teeth, 
notwithstanding  they  were  sound.     She.was  found  to 


ILLUSTRATIVE  CASES.  33 

have  astigmatism,  and  strong  cylindrical  glasses  were 
prescribed.  The  neuralgic  paroxysms  ceased  within 
a  few  days,  and  have  not  returned  during  eight  years. 

A  gentleman,  aged  twenty-eight,  an  extremely  neu- 
rotic subject,  was  seen  in  January,  1877.  He  had  for 
several  years  suffered  from  dorso-lumbar  neuralgia. 
He  was  extremely  sensitive  to  the  influence  of  cold. 
A  slight  draught  of  air  impinging  upon  the  back  was 
sufficient  to  bring  on  a  paroxysm  so  severe  as  to  con- 
fine him  several  days  in  his  bed.  He  slept  poorly, 
and  so  excessive  was  his  general .  nervous  derangement 
that  he  sometimes  felt  himself  upon  the  boundary  of 
insanity.  He  belonged  to  a  neurotic  family.  His 
mother  died  insane.  One  of  his  brothers  was  insane, 
and  a  sister  had  been  an  invalid  for  several  years 
from  some  nervous  disorder.  He  was  myopic,  with  a 
slight  astigmatism.  Glasses  to  meet  these  conditions 
were  prescribed  and  used.  Mne  months  later  he 
called  to  say  that  he  was  entirely  cured,  and  that 
the  relief  had  been  immediate. 

A  lady  who  had  suffered  from  facial  neuralgia  of 
intense  character  during  many  years,  was  found  to 
have  insufficiency  of  the  internal  recti  muscles.  Te- 
notomy of  one  of  the  external  recti  was  performed, 
since  which  time,  although  six  years  have  elapsed, 
she  has  had  no  attack  of  her  complaint. 

These  instances  serve  as  illustrations  of  irritation 
arising  from  uncomplicated  errors  of  refraction,  or  of 
association,  and  of  the  relief  often  obtained  by  the 
correction  of  these  uncomplicated  errors. 
•     But  it  often  happens  that  these  anomalies  are  not 


34  FUNCTIONAL  NERVOUS  AFFECTIONS. 

uncomplicateid.  Thus,  refractive  errors,  sucli  as  hy- 
permetropia  or  myopia,  are  often  associated  with  mus- 
cular insufficiencies,  either  of  those  directing  the  eyes 
laterally,  or  of  those  which  move  them  in  the  vertical 
direction.  Again,  insufficiency  of  either  of  these  mus- 
cles may  be  associated  with  weakness  of  the  muscle 
of  accommodation.  These  are  but  a  few  of  the  com- 
plications which  may  be  found,  and,  in  many  of  these 
nervous  complaints  in  which  the  predisposing  irrita- 
tion is  found  in  the  eyes  and  their  motor  apparatus, 
the  simple  correction  of  a  refractive  error  is  by  no 
means  sufficient  to  bring  relief  to  the  nervous  condi- 
tion. AYhen  once  a  neuralgic,  choreic,  or  epileptic 
habit  has  been  long  established,  not  only  may  it  be 
necessary  to  remove  the  principal  source  of  irritation, 
but  all  irritation,  before  the  habit  will  be  discon- 
tinued. It  must  not,  therefore,  be  supposed,  even  if 
the  hypothesis  that  refractive  and  muscular  errors  of 
the  eyes  constitute  a  very  important  factor  in  the 
neuropathic  condition,  that  the  simple  adjustment  of 
a  pair  of  glasses,  or  the  simple  relaxation  of  a  muscle, 
must  of  necessity  establish  the  cure  of  a  nervous 
disease. 

The  irritation  experienced  in  and  about  the  eyes, 
and  in  the  forehead  and  temples,  as  a  result  of  ame- 
tropia or  muscular  anomalies,  is  called  asthenoj^ia. 
It  is  a  complaint  for  which  oculists  are  very  frequent- 
ly consulted,  and  doubtless  yields  more  readily  than 
complaints  arising  from  the  same  cause  more  distantly 
located,  or  of  more  severe  nature ;  yet  it  is  well 
known  to  oculists  that  even  asthenopia  does  not  al- 


CEPHALALGIA  OR  HEADACHE.  35 

ways  yield  to  such  simple  measures  as  have  been 
mentioned. 

Hence  the  highest  skill  and  most  patient  effort  may 
be  demanded  for  the  removal  of  ocular  disturbances 
which  may  cause  nervous  troubles,  and  the  failure  of 
efforts  directed  only  to  some  prominent  ocular  defect 
would  not  of  necessity  argue  against  the  probability 
that  the  eyes  may,  after  all,  be  the  seat  of  trouble. 

Bearing  this  in  mind,  we  are  prepared  to  examine 
more  in  detail  a  few  forms  of  neuroses  and  thek  rela- 
tions to  ocular  defects. 

CEPHALALGIA   OE    HEADACHE. 

The  form  of  nervous  disturbance  more  common 
than  any  other,  perhaj)s,  is  headache.  The  habitual 
sufferers  from  this  comi^laint  are  everywhere,  and,  in- 
asmuch as  the  subjects  of  the  disorder  are  usually 
able  to  be  about,  and  generally  to  attend  to  the  ordi- 
nary duties  of  life,  they  are  forced  to  surrender  them- 
selves to  the  ever-returning  torture  with  as  much  resig- 
nation as  possible ;  and,  after  trying  many  remedies, 
almost  all  of  which  may,  for  a  brief  period,  seem  to 
modify  their  sufferings,  they  at  length  submit  passive- 
ly to  their  fate,  with  the  comforting  assurance  that  the 
disorder  is  constitutional,  and  that  nothing  can  be 
done. 

Although  headaches  take  a  variety  of  forms,  an 
outline  of  the  most  characteristic  features  of  the  dis- 
order may  be  drawn  in  such  a  general  manner  that  the 
details  of  the  picture  may  be  easily  filled  in  for  an 
individual  case. 


36  FUNCTIONAL  NERVOUS  AFFECTIONS. 

The  j)ain  most  usually  attacks  the  temples,  the 
supra-orbital  and  the  occipital  regions,  the  parts  with- 
in the  orbit,  and  more  rarely  the  top  of  the  head. 
It  is  more  or  less  paroxysmal,  sometimes  occurring 
with  comparative  regularity,  but  frequently  arising 
after  a  period  of  anxiety,  care,  worry,  or  excitement. 
In  many  cases  the  pain  is  continuous,  and  parox- 
ysms consist  simply  of  increase  of  the  ordinary  suf- 
fering. In  the  majority  of  females  examined  who 
have  been  habitual  sufferers  from  headache,  there  has 
been  found  habitual  pain  at  the  origin  of  the  tra- 
pezius muscles,  at  the  point  over  the  extremity  of 
the  spinous  process  of  the  seventh  cervical  vertebra, 
and  at  the  lower  angles  of  the  scapulae.  Less  com- 
mon, but  quite  characteristic  pains  accompanying 
headache  are  between  the  angles  of  the  scapulae  and 
at  the  lower  part  of  the  dorsal  region.  It  is  worthy 
of  observation  that  in  general,  if  pain  is  habitually 
experienced  at  the  lower  angles  of  the  scapulae,  it  is 
rarely  found  at  the  point  over  the  spinous  processes 
of  the  vertebrae  situated  between  those  points;  and, 
again,  if  pain  is  habitual  over  the  spinous  process  of 
the  seventh  cervical  vertebra,  it  may  be  presumed  to 
exist,  although  it  is  not  invariably  found,  at  one  of 
the  other  locations  below  it.  These  pains  occur  much 
less  frequently  in  men,  who,  more  than  women,  suffer 
from  dull  pains  at  the  occipital  region.  This  occipi- 
tal pain,  which  is  invariably  located  in  the  scalp  and 
occipital  muscle,  is  very  frequently  and  incorrectly 
spoken  of,  sometimes  even  in  medical  literature,  as 
"pain  at  the  base  of  the  brain." 


ATTENDANT  SYMPTOMS  NOT  CAUSATIVE.         37 

Other  sympathetic  pains  are,  at  the  turn  of  the 
shoulders  and  along  the  course  of  the  triceps  muscle, 
and  in  the  upper  portion  of  the  chest. 

Patients  suffering  from  headaches  are  frequently 
dyspeptics ;  they  often  suffer  from  insomnia,  and  ha- 
bitual constipation  is  also  a  not  infrequent  attendant 
condition. 

To  the  various  conditions  just  named,  the  head- 
aches are  often  attributed,  and  many  patients  feel 
sure  that  they  can  account  for  their  headaches  as  of 
stomachic  origin,  because  they  habitually  suffer  from 
disturbance  of  the  stomach  at  the  time  of,  or  Just 
before,  the  paroxysm  of  headache.  That  these  are 
simply  attendant  symptoms  and  not  causative  influ- 
ences, will  be  seen  as  we  advance,  and  the  fact  that 
an  indiscretion  in  diet,  or  an  enforced  loss  of  sleep, 
may  act  as  an  immediate  cause,  will  be  found  to  be 
explained  on  the  principle  of  increased  demand  upon 
nervous  energies  already  rendered  inadequate  to  the 
ordinary  demands  of  the  system,  and  that  this  in- 
creased demand  acts  in  the  same  manner  as  would 
other  calls  upon  the  nervous  energies. 

Habitual  sufferers  from  headaches,  although  often 
persons  of  highest  mental  culture  and  of  superior 
intellectual  endowments,  are  liable  to  suffer  from 
chronic  lassitude  and  inaptitude  to  set  themselves 
about  any  employment,  especially  if  it  demands  much 
mental  exercise.  In  some  cases  a  confusion  of  ideas 
is  so  conspicuous  a  symptom  that  patients  express 
fears  of  approaching  insanity.  There  is,  in  a  large 
proportion  of   instances,   a  general  nervous  imtabil- 


38  FUNCTIONAL  NERVOUS  AFFECTIONS. 

ity,  inability  to  continuous  exertion,  and  mental  de- 
pression. Still  other  cases  are  so  characterized  by 
general  impaired  functional  activity,  that  the  princi- 
pal local  manifestation,  the  headache,  is  apparently 
a  secondary  subject  of  attention.  Such  patients  ex- 
hibit symptoms  varying  in  a  considerable  degree,  ac- 
cording to  the  sex  of  the  individual,  and  the  cases 
are  known  as  spinal  irritation,  neurasthenia,  etc., 
conditions  to  which  attention  will  be  presently  di- 
rected. 

Chronic  headaches  are  common  among  those  who 
inherit  a  neuropathic  tendency;  by  far  the  greatest 
number  of  subjects  acquiring  the  predisposition  by 
inheritance.  Certain  collateral  influences  modify  the 
disease  in  a  marked  degree.  Thus,  a  residence  in  a 
malarial  district  may  give  to  the  complaint  a  more  dis- 
tinctly periodical  tendency,  and  subjects  of  headache 
passing  an  active  life  in  the  open  air  will,  in  general, 
ex]3erience  less  of  the  associated  neuralgic  j)ains  in  the 
back  and  sides  than  persons  of  sedentary  habits. 

The  most  important  facts  relating  to  the  etiology 
of  the  complaint  may  be  briefly  recapitulated  as  fol- 
lows :  It  is  an  exceedingly  chronic  disorder,  often 
relieved  temporarily,  but  rarely,  if  ever,  permanently 
cured  by  medicines.  It  is  often  traceable  to  the  earli- 
est years  of  the  patient.  The  tendency  is  frequently, 
if  not  generally,  hereditary.  It  is  usually  intermit- 
ting, and  demands  upon  the  nervous  energies,  slightly 
in  excess  of  those  ordinarily  required,  act  as  imme- 
diate causes.  We  also  find  that  other  symptoms  of 
nervous  disturbance,  such  as  insomnia,  dyspei)sia,  and 


NERVOUS  SYMPTOMS  INTERCHANGEABLE.        39 

pains  in  various  localities,  are  frequent  attendant  dis- 
orders. 

These  facts  lead  to  the  conclusion  that  the  cause  is 
permanent,  and  in  most  cases  commensurate  with  the 
life  of  the  patient ;  that  the  irritation  or  exhaustion 
affects  the  nervous  centers  and  is  reflected  to  various 
parts  at  a  distance  from  the  head  as  well  as  to  the  head 
itself.  Hence,  the  manifestations  of  nervous  exhaus- 
tion or  irritation  are  interchangeable.  Thus  it  is  that 
one  in  whom  the  irritation  may  have  been  for  a  long 
time  exhibited  as  habitual  headache  may,  from  some 
reason,  assignable  or  otherwise,  afterward  suffer  from 
dyspepsia,  neuralgia,  or  other  forms  of  nervous  dis- 
order from  the  same  irritation,  and  such  a  change  in 
the  form  of  disorder  does  not  indicate  a  cure  of  the 
first  disease,  but  only  a  different  manifestation  of  the 
same  trouble  from  the  same  cause. 

We  also  find  that  certain  modifying  influences, 
such  as  the  manner  of  life,  the  location  of  residence, 
and  the  occupation  of  the  individual,  contribute  to  lend 
certain  characteristics  to  the  complaint. 

We  are,  then,  applying  all  these  facts,  to  search  for 
some  cause  which  shall  most  generally  answer  to  all 
these  conditions.  It  must  be  permanent,  often  inher- 
ited. It  is  not  of  necessity  situated  at  the  seat  of 
pain,  and  is  as  capable  of  inducing  pain  or  distress  in 
one  part  as  in  another.  Such  a  cause  must  be  ana- 
tomical, and  it  is  reasonable  to  assume  that  it  acts  by 
causing  inordinate  demand  ujDon  the  nervous  energies 
in  the  performance  of  some  function  or  functions,  thus 
reducing  the  ordinary  standard  of  nervous  power  in 


40  FUNCTIONAL  NERVOUS  AFFECTIONS. 

such  a  manner  that  slight  additional  demands  cause 
marked  irregularity  of  nervous  action,  permitting 
agencies  which  might  not  otherwise  induce  disease  in 
the  individual  to  become  under  these  circumstances, 
capable  of  exerting  important  modifying  influences. 
It  may  be  said  in  general  that  any  anatomical  con- 
dition which  would  render  the  execution  of  an  impor- 
tant and  constantly  performed  function  difficult  might, 
by  so  reducing  the  amount  of  nervous  energy,  become 
a  neuropathic  predisposition. 

This  principle  being  established,  it  remains  to  de- 
termine, if  possible,  whether  difficulties  in  performing 
any  one  function  more  often  act  as  such  predisposi- 
tion, than  those  attending  the  performance  of  other 
functions. 

This  question  can  not  be  satisfactorily  settled  upon 
theoretical  principles  independently  of  practical  re- 
sults. If  it  should  theoretically  appear  probable  that 
this  irritating  or  exhausting  influence  is  to  be  found 
more  frequently  located  in  one  organ  or  set  of  organs 
than  another,  and  should  assistance  in  the  performance 
of  the  functions  of  that  organ  or  set  of  organs  be  quite 
uniformly  followed  by  a  relief  from  the  disturbances 
previously  experienced,  a  reasonable  ground  would 
exist  for  concluding  that  the  most  general  cause  had 
been  discovered. 

It  has  already  been  shown  that,  in  the  performance 
of  the  visual  act,  difficulties  of  no  insignificant  char- 
acter are  very  frequently  encountered.  These  diffi- 
culties are  often  permanent,  and  are  to  a  great  extent 
hereditary.    The  nervous  strain  arising  from  visual 


PRESENT  CIVILIZATION  AND  NEUROSES.  41 

defects,  organic  or  functional,  is  great  in  proportion 
as  the  present  civilization  makes  greater  demands  upon 
the  visual  function  than  has  any  previous  civilization  ; 
and  the  neuroses  of  the  character  which  we  are  con- 
sidering are  notably  more  numerous  at  the  present 
time  than  in  former  times.  That  this  increase  in  nerv- 
ous disorders  is  not  a  result  of  any  deterioration  of 
physical  power  among  the  civilized  nations  of  the 
present  time  is  apparent  when  we  remember  that  the 
duration  of  life  is  now  greater  and  the  average  capaci- 
ty of  labor  is  probably  greater  among  civilized  people 
of  the  present  age  than  among  those  of  former  cent- 
uries. 

If  it  can  be  shown  that  a  very  considerable  propor- 
tion of  chronic  headaches  are  relieved  by  the  removal 
of  exhausting  or  perplexing  conditions  from  the  eyes, 
the  theory  that  such  conditions  are  among  the  initial 
causes  will  be  established. 

A  few  cases  somewhat  in  detail  will  illustrate  the 
manner  in  which  such  relief  is  obtained.  These  cases 
do  not  differ  essentially  from  several  hundreds  of 
others,  either  in  their  general  features  or  in  the  re- 
sults of  treatment : 

Mr.  W.  N.  B.,  consulted  March  16,  1881.  He 
has  for  six  years  past  suffered  extreme  pain  in 
the  top  of  the  head  and  in  the  occipital  and  tem- 
poral regions.  He  is  never  free  from  pain  when 
awake.  He  is  in  an  extremely  irritable  state,  rests 
poorly  at  night,  has  more  or  less  backache,  and 
is  always  constipated.  His  face  is  usually  flushed, 
although  he  is  of  strictly  temperate  habits ;  and 


42  FUNCTIONAL  NERVOUS  AFFECTIONS. 

he  is  mucli  troubled  with,  vertigo.  He  has  been 
forced  to  resign  his  position  as  secretary  in  a  large 
public  institution,  and  during  the  two  months  i>Ye- 
ceding  his  visit  has  been  an  inmate  of  an  excellent 
hospital,  where  he  has  been  under  treatment.  Al- 
though somewhat  rested,  he  has  obtained  no  relief 
from  the  nervous  symptoms. 

He  was  found  to  have  hypermetropia  2*50  dioi)trics, 
and  insufficiency  of  the  external  recti  muscles. 

Convex  glasses  1*5  D.  were  prescribed,  which  were 
soon  replaced  by  convex  2 "00  D.  Partial  tenotomy  of 
one  of  the  internal  recti  muscles  was  made,  and  the 
operation  was  soon  followed  by  a  similar  one  on  the 
other  eye. 

The  patient  rapidly  improved,  and  was  in  a  few 
weeks  able  to  return  to  clerical  duty.  This,  however, 
he  afterward  resigned  for  a  more  active  life,  and  his 
health  has  remained  entirely  good  during  the  interval 
of  two  and  a  half  years. 

Mrs.  J.  D.,  aged  fifty-seven,  consulted  February 
24,  1881.  Has  had  headaches  since  she  was  fifteen 
years  old.  Is  a  large,  well-developed  woman,  ap- 
parently vigorous.  Paroxysms  occur  at  intervals 
of  from  once  a  week  to  once  in  two  weeks.  They 
are  of  great  intensity,  and  not  infrequently  quite 
alarming  to  friends  and  physicians.  In  the  inter- 
vals she  suffers  from  sciatica,  from  mental  depres- 
sion, from  dull  headaches,  palpitation  of  the  heart, 
and  dyspepsia.  Two  sisters  are  subject  to  chronic 
headaches. 

Examination  of  the  eyes  shows  that  she  has  a 


EXERCISE  OF  OCULAR  MUSCLES.  43 

moderate  degree  of  astigmatism  and  deficient  ad- 
ducting  force. 

Convex  cylinders  were  prescribed  and  used  witli  a 
combination  of  spherical  and  cylindrical  for  reading 
purposes,  and  the  adducting  power  was  increased  by 
systematic  exercise  of  the  internal  recti  muscles  with 
prisms. 

March  23d,  has  perfect  converging  power.     Has 

had  no  headache  during  the  past  two  weeks. 
April  10,  1883.     Has  during  the  interval  of  more 

than  two  years  been  entirely  free  from  headaches. 

Has  no  more  dyspepsia,  palpitation,  or  sciatica,  and 

her  present  call  is  only  in  regard  to  a  change  of 

reading-glasses. 

Reference  is  made  in  the  above  case  to  exercise  of 
the  ocular  muscles,  which  is  accomplished  by  means 
of  prisms  which  the  ocular  muscles  are  called  upon  to 
overcome  in  order  to  maintain  single  vision  ;  prisms  of 
gradually  increasing  strength  being  employed. 

As  other  references  to  such  exercising  of  the  ocular 
muscles  will  be  made,  it  is  proper  to  anticipate  with 
a  few  words  what  will  be  stated  more  at  length  further 
on  in  regard  to  it. 

Exercise  having  the  same  object  in  view  and  per- 
formed in  a  somewhat  similar  manner  to  that  which 
will  be  hereafter  described,  was  formerly  employed  to 
some  extent  for  the  relief  of  insufiiciency  of  the  in- 
ternal recti  muscles.  As  the  experience  of  oculists 
generally  proved  that,  in  the  majority  of  cases  in 
which  insufficiency  arising  from  actual  disproportion 
of  the  recti  muscles  exists,   this  is  quite  inadequate, 


44  FUNCTIONAL  NERVOUS  AFFECTIONS. 

the  exercise  has  been  for  several  years  very  generally 
abandoned. 

In  the  cases  in  which  it  is  referred  to  in  this  essay, 
there  has  existed,  for  the  most  part,  an  insufficient  ad- 
ducting  energy,  but  no  very  considerable  degree  of  in- 
sufficiency such  as  would  be  shown  by  the  dot  and  line 
test  of  Yon  Graefe. 

The  distinction  between  the  two  forms  of  insuffi- 
ciency will  be  dwelt  upon  more  at  length  in  its  appro- 
priate place,  and  it  remains  only  to  say  here  that  such 
exercise  in  suitable  cases  proves  of  infinite  benefit. 
Hereafter  the  term  "insufficient  adducting  power" 
will  be  used  to  describe  the  condition  amenable  to  such 
exercises,  while  the  term  "insufficiency  of  the  internal 
or  external  recti  muscles  of  a  stated  number  of  de- 
grees "  will  express  the  condition  commonly  described 
as  insufficiency  of  the  recti  muscles. 

The  following  case  illustrates  a  very  frequent  cause 
of  headache  and  of  other  nervous  symptoms : 

A  young  gentleman  had  for  several  years  suffered 
almost  continuous  headache  during  waking  hours. 
His  plans  of  life  had  been  seriously  modified  by  the 
constant  torture  he  suffered,  and  he  was  often  in 
charge  of  a  physician. 

Deficient  energy  of  the  ciliary  muscles  in  the  act  of 
accommodation  was  supposed  to  be  the  cause  of  his 
trouble.  Tablets  containing  small  quantities  of  ex- 
tract of  Calabar  bean  were  placed  upon  the  eyes  daily 
for  a  few  days  in  succession,  followed  by  the  occa- 
sional but  less  frequent  use  of  the  same  agent  for 
two  weeks.    At  the  end  of  that  time  he  was  greatly 


RELIEF  FROM  REMOVAL  OF  CAUSE.  45 

improved,  and  in  a  month  quite  well  of  his  headaches. 
Four  years  have  passed  with  no  serious  return  of  his 
old  complaint,  and  a  threatened  attack  can  be  averted 
by  a  single  instillation  of  a  solution  of  eserine  into 
the  eyes. 

Severe  and  long- continued  headaches  are  sometimes 
accompanied  by  excessive  symptoms  of  exhaustion, 
coldness  of  the  extremities,  and  loss  of  muscular  elas- 
ticity. 

Annie  W.,  age  ten  years,  was  brought  for  ex- 
amination in  September,  1880.  She  had  been  al- 
ways subject  to  severe  headaches,  located  in  the 
temples  and  back  of  the  head.  Although  rarely 
free  from  suffering,  her  pains  are  greater  if  she  at- 
tempts to  look  at  books.  She  is  very  pale  and 
thin ;  walks  feebly,  and  seems  quite  exhausted 
with  very  moderate  exercise.  The  facial  mus- 
cles are  so  little  active  that  she  seems  expression- 
less. Her  speech  lacks  energy,  and  in  all  respects 
she  seems  to  be  in  a  state  of  great  nervous  ex- 
haustion. 

There  was  found  in  this  case  marked  insuflB.ciency 
of  the  external  recti  muscles  and  very  slight  adductive 
power  when  accommodation  was  relaxed. 

After  increasing  the  adducting  power  by  exercise, 
partial  tenotomy  of  the  internal  rectus  was  performed 
under  the  influence  of  chloroform. 

The  child  commenced  very  soon  to  gain  strength 
and  elasticity ;  expression  came  to  the  face  and  vigor 
to  the  limbs  ;  the  headaches  ceased  and  mental  energy 
followed.     She  has  continued  well  during  the  thi-ee 


46  FUNCTIONAL  NERVOUS  AFFECTIONS. 

years,  and  is  now  advanced  in  her  studies  beyond  most 
of  her  companions  of  the  same  age. 

The  two  portraits  of  Plate  I,  reproduced  from 
photographs,  represent  a  child  ten  years  of  age, 
who  from  infancy  had  been  the  victim  of  head- 
aches. She  was  feeble,  always  tired,  and  rarely 
free  from  pain.  Attempts  to  send  her  to  school 
had  proved  unsuccessful,  for  she  no  sooner  com- 
menced attendance  than  she  became  prostrated. 
She  had  insufficiency  of  the  externi,  and  operations 
for  its  relief  was  made,  upon  one  eye  June  8,  1883, 
and  upon  the  other  June  12th.  It  is  needless  to 
tell  one  who  examines  these  two  pictures  that  the 
change  was  marvelous.  The  weary,  heavy,  discour- 
aged aspect  of  the  child  as  shown  by  the  portrait 
of  June  8th  is  in  remarkable  contrast  with  that 
of  June  20th,  where  vivacity  and  courage  are 
embodied  in  her  expression.  The  child  returned 
home  to  enter  school,  where  she  has  done  excel- 
lent work. 

In  the  cases  above  cited,  headaches  have  been  re- 
lieved by  the  removal  of  irritation  induced  by —  1.  Hy- 
permetropia,  with  insufficiency  of  the  external  recti ; 
2.  Astigmatism,  with  enfeebled  adducting  force ;  3. 
Enfeebled  energy  of  the  muscles  of  accommodation ; 
and,  4.  Insufficiency  of  the  external  recti  muscles 
uncomplicated  with  any  very  important  refractive 
error. 

It  will  thus  appear  that  these  various  conditions  of 
refractive  and  muscular  anomalies  may  act  as  dispos- 
ing causes  of  headaches,  and  that  the  removal  of  the 


f^^:a»M:_. 


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GENEEAL  RESULTS  IN  CEPHALALGIA.  47 

irritation  arising  from  such  conditions  is  sufficient  to 
afford  permanent  relief  to  the  nervous  suffering. 

The  number  of  cases  of  chronic  headache*  in  the 
jjrivate  practice  of  the  author,  in  which  examinations 
of  the  ocular  conditions  have  been  made,  is  twelve 
hundred  and  eighty.  For  nearly  all  these,  advice  in 
regard  to  the  correction  of  the  ocular  defects  has  been 
rendered ;  but,  inasmuch  as  the  period  during  which 
these  examinations  have  been  made  extends  through 
several  years,  it  is  manifest  that  it  is  impossible  to 
know  the  result  of  this  advice  in  all  cases,  A  very 
large  proportion  of  these  are  transient  cases,  in  which 
a  single  consultation  has  concluded  the  relation  of 
physician  and  patient,  and  as  many  of  the  cases  reside 
in  cities  distant  from  the  residence  of  the  writer,  some 
even  of  those  who  receive  treatment  for  a  longer  time 
are  lost  to  observation.  In  order,  however,  to  arrive  at 
some  basis  of  facts  from  which  one  not  in  the  constant 
observation  of  these  phenomena  may  be  enabled  to 
draw  some  conclusion  as  to  their  value,  an  analysis  of 
the  results  in  one  hundred  consecutive  cases  of  chronic 
headache  is  here  given.  The  list  extends  backward 
from  December  31,  1882,  to  the  2d  of  June  of  the 
same  year.  This,  while  allowing  sufficient  time  to  have 
elapsed  since  the  most  recent  date,  to  determine  the 
permanent  results,  is  also  sufficiently  recent  to  enable 
a  recollection  of  the  cases  in  some  measure  to  supple- 
ment the  written  record. 

Proceeding,  then,  to  the  analysis  of  these  cases,  it 

*  Chronic  in  the  sense  of  continuing  during  more  than  one  and  in 
general  during  several  years. 


48  FUNCTIONAL  NERVOUS  AFFECTIONS. 

is  found  that  of  tlie  number,  nothing  is  known  of  the 
patients  after  their  first  consultation  in  twenty-two 
cases.  In  five  other  cases,  in  which  more  than  a  single 
visit  was  made,  no  knowledge  of  the  subsequent  his- 
tory is  possessed.  Sixty-one  are  known  to  have  ob- 
tained permanent  relief.  Mne  are  known  to  have 
received  temporary  and  marked  improvement,  while 
in  three  cases  no  improvement  resulted. 

If  we  exclude  the  twenty-seven  cases  the  history 
of  which,  since  the  examinations  or  after  a  very  few 
calls,  are  unknown,  we  shall  find  that  the  proportion 
to  one  hundred  is  as  follows : 

Permanently  relieved 83*6  per  cent. 

Improved 12'4        " 

Not  cured 4  " 

100 

It  should  be  observed,  in  passing,  that  the  cases 
upon  which  these  statistics  are  based  are  in  all  re- 
spects typical  cases  of  chronic  headache,  of  which  the 
illustrative  cases  given  above  are  fair  examples.  No 
cases  of  simple  asthenopia  or  of  temporary  headaches 
are  included. 

It  should  be  further  remarked  that  in  these  cases 
drugs  have  not  been  administered,  except  in  rare  in- 
stances, for  temporary  relief  of  some  other  symptom, 
and  in  no  case  can  the  influence  of  drugs  be  re- 
garded as  a  factor  in  the  result  of  the  treatment. 
This  statement  will  also  apply  to  classes  of  cases  here- 
after to  be  reported.  In  fact,  the  results  in  these 
cases  must  be  attributed  solely  to  the  removal  of  the 


CEPHALALGIA.  49 

difficulties  incident  to  the  performance  of  tlie  visual 
act. 

As  has  already  been  said,  every  oculist  recognizes 
the  fact  that  asthenopia  is  a  complaint  resulting  gener- 
ally from  ocular  defects  or  insufficiencies  of  the  ocular 
muscles.  Yet  it  is  equally  well  known  that  this  more 
immediate  and  much  less  severe  form  of  irritation  does 
not  always  yield  to  the  means  employed  for  its  treat- 
ment. But  if  we  compare  the  results  of  treatment  of 
asthenopia  with  the  results  obtained  in  the  treatment 
of  headaches  by  similar  means,  we  can  not  fail  to  see 
that  the  latter  form  of  complaint  yields  as  often  to 
treatment  directed  to  correction  of  anomalies  of  re- 
fraction and  accommodation  or  of  muscular  insuffi- 
ciencies as  does  the  former.  Hence  we  may  logically 
draw  the  conclusion  that  headaches  are  as  generally 
the  result  of  disturbing  ocular  conditions  as  is  asthe- 
nopia. 

It  is  to  be  further  observed  that  the  relief  is  not 
the  result  of  temporary  stimulation  of  nervous  energy, 
such  as  might  result  from  the  use  of  electricity,  or  of 
certain  drugs,  or  a  change  of  air  or  surroundings. 
Either  or  all  of  these  measures  might  bring  relief  in 
certain  cases,  but  if  the  fundamental  cause  remains,  it 
is  only  relief,  and  can  not  be  properly  regarded  as  a 
cure,  of  the  predisposing  tendency. 

In  cases  of  temporary  nervous  disturbance,  result- 
ing in  headaches,  the  agencies  above  mentioned  may 
be  used  with  advantage,  but  they  certainly  have  no 
power  to  remove  an  hereditary  cause. 

Further    consideration    of   the   treatment    of   this 


50  FUNCTIONAL  NEEVOUS  AFFECTIONS. 

special  class  of  troubles  may  be  reserved  for  consid- 
eration under  the  general  discussion  of  therapeutical 
measures  in  nervous  comi)laints. 

Nearly  related  to  this  class  of  troubles  is  migraine, 
a  complaint  often  classed  with  neuralgia,  but  which 
has  characteristics  so  clearly  defined  that  it  may  well 
rank  as  a  distinct  form  of  nervous  disturbance. 

MIGEAIJiTE,    OR  SICK-HEADACHE. 

Paroxysms  occur  with  greater  or  less  regularity  in 
respect  to  time,  the  intervals  being  in  some  cases  only 
a  few  days,  in  others  a  month  or  more.  The  attack 
commences  in  most  cases  with  a  feeling  of  lassitude 
and  dull  headache,  the  eyes  are  painful,  and  the  act 
of  turning  them  quickly  or  far  is  attended  with  dis- 
tress. The  effect  of  light  is  disagreeable,  and  there 
is  mental  disquietude.  In  some  instances  the  attack 
is  ushered  in  by  great  disturbance  of  vision,  sometimes 
described  as  glimmerings  and  confusion.  At  other 
times  the  visual  defect  assumes  the  form  of  hemiopia, 
or  even  of  complete  blindness.  The  visual  disturbance 
lasts  from  a  few  seconds  to  an  hour,  and  such  attacks 
are  known  as  "blind  headaches." 

The  subject  of  an  attack,  after  a  few  hours  of  these 
premonitory  symptoms,  resorts  to  the  bed,  the  j^ain 
over  and  through  the  eyes  becoming  more  and  more 
intense,  and  the  effect  of  light  more  tormenting.  Slight 
sounds  or  feeble  currents  of  air  are  often  unendurable, 
and  nausea  and  vomiting  supervene.  The  pain  is  in 
many  cases  confined  to  one  side,  and  in  some  uniform- 
ly to  the  same  side,  in  various  attacks.     In  others  the 


MIGRAINE.  51 

pain  is  alternately  located  on  one  or  the  other  side, 
and,  in  case  of  visual  disturbance  of  one  eye  only, 
the  headache  is  often  situated  upon  the  opposite  side 
of  the  head  to  the  eye  affected.  The  headache  as 
well  as  the  visual  disturbance  may,  however,  be  bi- 
lateral. 

In  a  few  cases  of  '•'blind"  headaches,  in  which  the 
fundus  of  the  eyes  have  been  examined  with  the  oph- 
thalmoscope during  the  period  of  visual  disturbance^ 
the  retina  has  been  found  pale  and  brilliant,  the  optic 
disc  unusually  white,  and  the  main  arteries  somewhat 
irregularly  contracted  in  their  course.  In  these  cases 
the  field  of  vision  has  been  found  to  be  contracted  in 
a  striking  manner,  in  some  instances  one  half  of  the 
field  being  completely  lost,  while  in  others  the  central 
field  was  gone,  imperfect  sight  only  remaining  at  the 
periphery. 

A  night's  sleep  may  bring  relief,  or  the  paroxysm 
may  continue  for  several  days,  during  which  delirium 
or  loss  of  consciousness  may  become  prominent  symp- 
toms. 

The  attack  being  over,  there  may  remain  some 
symptoms  of  the  nervous  prostration  for  a  day  or 
two,  but  the  patient  is  soon  more  than  usually  well 
for  a  period  of  one  or  several  days,  and  the  subjects 
of  the  complaint  are  often  extremely  vivacious  and 
energetic  in  the  intervals  between  the  attacks.  This 
is,  however,  not  always  the  case,  as  a  certain  propor- 
tion of  the  subjects  of  this  malady  are  rarely  free  from 
a  dull  headache,  pains  at  the  spinous  process  of  the 
lower  cervical  vertebra,  and  at  the  lower  angles  of  the 


52  FUNCTIONAL  NERVOUS  AFFECTIONS. 

scapula.  Palpitation  of  tlie  heart  and  general  nervous 
irritability  are  also  among  tlie  continuous  symi)tonis. 

The  history  of  the  affection  often  goes  back  to  the 
earliest  recollections  of  the  patient,  and  in  nearly  all 
cases  a  vast  number  of  supposed  remedies  have  been 
tried,  sometimes  with  slight  temporary  relief,  but  more 
frequently  without  any  good  results.  In  a  consider- 
able number  of  cases  the  affection  is  developed  during 
school- days,  a  circumstance  which  has  led  to  the  ab- 
horrent supposition  that  it  results  mostly  from  impure 
thoughts  and  practices. 

Fortunately,  this  is  a  gross  libel  ujDon  a  class  of 
humanity  on  the  whole  characterized  by  frankness  and 
intelligence.  If  we  remember  that,  at  the  age  of  from 
eight  to  fifteen,  nearly  all  of  the  children  in  whom  this 
affection  is  found  are  at  school,  closely  pursued  by 
examinations  and  a  multitude  of  studies,  we  shall  see 
that  the  demand  upon  the  ocular  muscles  is  excessive, 
and  that  this  demand  is  for  the  most  part  made  in 
crowded  school-rooms,  where  the  air  is  vitiated,  and 
nerves  and  muscles  are  thereby  rendered  less  capable 
of  enduring  the  strain.  Again,  these  subjects  of  mi- 
graine are,  as  a  class,  unusually  ambitious,  and  such 
children  maintain  advanced  positions  in  their  classes 
at  an  expense  of  eye-strain  even  greater  than  that 
which  attends  the  exercise  of  the  eyes  of  the  less  am- 
bitious pupil.  If,  added  to  this,  there  is  an  anatomi- 
cal or  physiological  reason  for  unusual  strain  in  doing 
the  ordinary  work  of  the  eyes,  we  have  a  combination 
of  circumstances  conspiring  against  the  strength  of 
these  children. 


MIGRAINE.  53 

This  is  not  only  tlie  more  true  but  the  more  gen- 
erous explanation  of  the  occurrence  of  these  attacks, 
at  this  period  of  life,  than  the  one  alluded  to ;  and  the 
author,  after  a  careful  investigation  of  both  sides  of 
this  question,  feels  justified  in  earnestly  protesting 
against  the  unjust  insinuation. 

Some  patients  suffer  less  when  absent  from  home, 
occupied  in  travel  or  repose,  or  when  engaged  upon 
light  duties  which  permit  them  to  be  much  in  the 
open  air.  Tonic  medicines  also  sometimes  increase 
the  intervals  between  the  attacks  and  render  them 
less  severe.  The  temporary  relief,  however,  which 
lengthens  the  intervals  or  modifies  the  attacks  can  not 
be  regarded  as  a  cure.  And  a  cure  can  only  be  assumed 
when  so  long  a  period  of  time  has  elapsed  since  a  last 
attack  that,  under  ordinary  circumstances,  in  the  par- 
ticular case,  a  very  large  number  of  attacks  could 
reasonably  have  been  expected.  Again,  as  in  case 
of  most  functional  nervous  diseases,  there  is  a  tend- 
ency to  a  change  in  the  form  of  the  complaint,  and 
one  subject  for  several  years  to  migraine  may  find 
that  he  has  no  longer  sick-headaches,  but  is  a  sufferer 
from  some  form  of  neuralgia,  perhaps  equally  dis- 
tressing with  the  former  complaint.  Such  a  case  can 
not  be  regarded  as  cured.  There  has  been  simply  a 
change  in  the  manifestation  of  nervous  irritation.  In 
all  these  cases  there  is  an  underlying  cause,  which  is 
to  be  found  and  removed.  This  accomplished,  a  per- 
manent cure  may  be  anticipated. 

Here,  as  in  the  case  of  the  more  ordinary  forms  of 
headache,  it  will  be  found  that  ocular  defects  play  a 


54  FUNCTIONAL  NERVOUS  AFFECTIONS. 

conspicuous  role  as  causative  conditions  in  migraine. 
According  to  the  experience  of  the  author,  these  de- 
fects constitute  by  far  the  greatest  factor  in  these 
cases.  Unlike  the  ordinary  forms  of  headache,  how- 
ever, migraine  does  not  so  frequently  yield  to  the 
simple  measures  of  adapting  glasses  to  correct  re- 
fractive errors.  There  is  often  a  complicated  state  of 
refractive  trouble  and  muscular  insufficiency,  demand- 
ing greater  care  and  judgment  in  correcting  the  ocular 
conditions.  With  sufficient  accuracy  in  relieving  these 
defects,  however,  sick-headaches  will,  in  the  great  ma- 
jority of  cases,  cease. 

The  following  are  not  only  typical  cases  of  sick 
headaches,  but  are  illustrations  of  the  ordinary  results 
of  treatment  directed  to  ocular  defects  in  a  great  num- 
ber of  cases : 

Miss  N.,  aged  seventeen.  November,  1880.  Had 
during  the  past  three  years  suffered  greatly  from 
"blind  headaches."  She  was  delicate,  anaemic, 
suffering  from  nervous  irritability  almost  charac- 
teristic of  chorea,  and  quite  unable  to  endure  ordi- 
nary physical  exercise.  Paroxysms  of  headache 
occurred  once  or  twice  a  week,  and  lasted  one  or 
two  days.  The  onset  of  the  attack  was  uniformly 
marked  by  a  total  loss  of  one  half  the  field  of  vision 
and  enfeebled  vision  in  the  remaining  half  of  both 
eyes.  The  hemiopia  was  heteronymous,  the  tem- 
poral portion  of  the  field  of  each  eye  being  lost. 
After  half  or  three  fourths  of  an  hour  of  this  visual 
disturbance,  which  was  associated  with  pain  over 
the  eyes  and  through  the  orbits,  and  with  a  general 


MIGRAINE. 


65 


sense  of  chilliness,  tlie  orbital  and  frontal  head- 
ache became  most  intense,  nausea  followed,  and 
the  patient  was  forced  to  retire  to  her  bed  in  ex- 
treme torture  and  iDrostration.  Vomiting  usually 
occurred,  but  not  uniformly.  If  she  could  fall 
asleep,  a  night's  rest  might  bring  relief,  but  the 
attacks  not  unfrequently  continued  until  after  the 
second  night. 

During  the  period  of  visual  disturbance  of  one  of 
these  attacks  the  eyes  were  examined,  with  the  fol- 
lowing results:  The  field  of  vision  was  contracted  in 
all  directions,  but  more  especially  in  the  outer  portion, 
as  shown  in  the  dia- 
gram which  repre- 
sents the  field  of  the 
right  eye. 

Vision  was  f^, 
the  letters  of  the 
trial-card  appearing 
and  disappearing. 
The  ophthalmoscope 
showed  the  disc 
pale,  the  arteries 
rather  small,  the  red 
cylinder  of  the  larger 
being  bordered  with 

white  lines  representing  the  unusually  conspicuous 
sheaths  of  these  vessels.  The  veins  were  rather  large. 
The  general  background  lighted  up  well,  but  was  of 
paler  red  than  usual. 

The  young  lady's  mother,  who  had  died  in  child- 


FiG.  2. 


56  FUNCTIONAL  NERVOUS  AFFECTIONS. 

birtli,  had,  during  several  years  preceding  the  time  of 
her  death,  suffered  from  chorea,  and  her  father  was  a 
neurotic  subject. 

No  physical  cause  for  these  frequent  and  torturing 
nervous  disturbances  was  found  elsewhere  than  in  the 
eyes  and  their  appurtenances.  She  had  a  moderate 
degree  of  astigmatism,  and  very  feeble  adducting  power. 
Cylindrical  glasses  were  employed  to  correct  the 
astigmatism,  and  the  adducting  power  was  developed 
by  systematic  exercise  of  the  muscles,  until  complete 
associative  action  was  established.  After  about  three 
weeks  the  headaches  ceased  entirely,  her  strength  im- 
proved rapidly,  and  she  was  soon  in  excellent  health. 
In  June  following  a  slight  return  of  the  trouble  caused 
her  to  direct  renewed  attention  to  the  condition  of  the 
eyes,  when  it  was  found  necessary  to  renew  the  exer- 
cise of  the  ocular  muscles  for  a  few  days.  Since  that 
time  she  has  continued  well. 

Migraine  not  unfrequently  alternates  with  intense 
neuralgic  headaches  in  which  nausea  is  absent,  or  the 
one  form  of  trouble  may  replace  the  other  perma- 
nently. 

Mrs.  H.,  aged  forty.  February,  1879.  Is  an 
exceedingly  active  woman  when  well,  but  during 
nearly  all  her  life  has  been  subject  to  frequent 
and  tormenting  attacks  of  migraine,  which  during 
the  past  year  have  alternated  with  neuralgic  head- 
aches. She  rarely  passes  a  week  without  being 
confined  to  her  bed  from  one  to  three  days.  As 
soon  as  the  attack  of  headache  or  neuralgia  is  over, 
she  is  ready  to  drive  out,  and  almost  compensates 


MIGRAINE.  57 

by  Iter  unusual  energy  for  the  time  lost  in  bed- 
She  is,  however,  rarely  without  pain  in  the  head 
and  back,  and  often  passes  whole  nights  without 
sleep.  She  has  also  for  many  years  had  neuralgia 
in  the  eyes  and  face.  The  eyes  being  examined, 
she  is  found  to  have  hypermetropia  manifest,  1 
Dioptry,  and  to  have  markedly  insuflScient  adduc- 
tive  power. 

Convex  glasses  were  prescribed  and  used,  and  the 
adducting  power  increased  to  the  proper  degree  by 
exercise.  The  headaches  and  neuralgic  troubles  ceased 
when  once  this  was  accomplished,  and  during  the  sev- 
eral years  intervening  she  has  continued  well. 

Many  patients  from  distant  cities,   or  even  those 
residing  in  the  vicinity,  after  making  one  or  two  calls 
may  discontinue  their  visits  and  make  no  report  of 
their  progress.     Necessarily,  in  such  instances,  noth- 
ing can  be  known  of  the  result  of  advice  given,  or 
whether  the  advice  has  been  accepted.     Some  of  these 
transients,  however,  make  their  appearance  after  longer 
or  shorter  intervals,  and  the  result  of  the  single  inter- 
view is  first  learned  by  the  physician,  perhaps,  after 
several  years.  The  following  is  an  instance  of  this  kind : 
Mr.  J.  F.  de  L.,  aged  forty-five,  consulted  June 
4,  1879,  on  account  of  sick-headaches  of  unusual 
intensity.      Since  early  boyhood  he  has  been  sub- 
ject to  attacks  occurring  with  great  frequency,  the 
interval  between  attacks  being  rarely  as  much  as 
four  and  more  frequently  not  more  than  two  days. 
He  describes  the  paroxysms  as  follows :  Pain  com- 
mences in  the  temples  and  forehead,  and  becomes 


68  FUNCTIONAL  NERVOUS  AFFECTIONS. 

more  intense  and  general  until  nausea  and  vomiting 
set  in,  when  he  retires  to  his  bed.  His  wife  sj^ends 
the  night  in  applying  lotions  and  applications  to 
his  head,  and  bathing  his  feet  in  hot  water.  He 
is  accustomed  to  take  1*5  gramme  bromide  of  po- 
tassium with  sulphate  of  morphia  O'l  centigramme 
combined,  and  repeated  at  intervals  of  one  or  two 
hours,  with  slight  relief.  The  paroxysm,  however, 
rarely  continues  less  than  twenty-four  hours.  He 
has  spent  much  time  in  traveling  in  mild  climates, 
hoping  to  gain  relief,  but  has  often  returned  worse 
than  he  went  from  home. 

He  was  found  to  have  astigmatism,  corrected  by 
lenses  of  the  following  combination :  Spher.  0*50 
D.,  cylind.  1  D.,  axis  90°,  which  were  advised  for 
constant  use. 

He  was  not  seen  again  until  June  28,  1883  (more 
than  four  years),  when  he  called,  saying  that  he  had 
used  the  glasses  prescribed,  and  had,  during  the  four 
years,  been  almost  entirely  free  from  the  tormenting 
affection  which  had  followed  him  during  a  great  por- 
tion of  his  life,  but  that  within  a  few  weeks  he  had 
suffered  a  few  slight  attacks.  It  was  found  that  the 
spectacle-frames  had  become  so  bent  as  to  give  the 
cylinders  an  improper  axis.  The  frames  were  bent 
into  position,  and  the  patient  advised  to  observe  care 
in  keeping  them  so. 

Only  two  cases  are  given  as  additional  illustrations, 
the  first  without  dwelling  upon  details.  Both  are 
typical  cases  of  sick-headache : 

Mrs.  M.,  aged  thirty-two.     June  3,  1882.     Dura- 


MIGRAINE.  59 

tion  fifteen   years ;    attacks    about    once  a  week. 
Eyes  trained  two  weeks. 

October  7,  1883.  Is  in  perfect  health.  Has  not 
had  attack  of  migraine  since  first  week  in  June, 
1882.  No  such  respite  has  been  kno^vn  in  past 
fifteen  years. 

Miss  Alice  S.  was  brought  by  her  physician,  Dr. 
William  Stevens,  October  2,  1882. 

The  patient  is  twenty-nine  years  of  age.  Is 
rather  tall,  of  fine  form,  but  thin  in  flesh  and  ex- 
tremely pale.  The  lips  are  colorless  and  the  ocular 
conjunctiva  of  pearly  white.  She  has  had  migraine 
once  or  twice  a  week  during  the  past  nine  years. 
The  pain  is  always  unilateral,  attacking  one  or 
other  eye  and  supraorbital  region,  and  extending 
downward  along  the  course  of  the  branches  of  the 
fifth  nerve.  With  each  attack  she  is  forced  to  re- 
tire to  her  bed,  and  intense  nausea  and  vomiting 
are  always  present.  A  night's  sleep  often  brings 
relief. 

In  this  case  there  was  found  to  exist  compound 
myopic  astigmatism  (M.  3-50  D.  +  A  M.  1*25  D),  with 
insuflSiciency  of  the  internal  recti  muscles  27°. 

Glasses  for  correcting  the  refractive  error  were  pre- 
scribed, and  tenotomy  of  one,  and  soon  after  of  the 
other,  external  rectus  was  made,  fully  correcting  the 
insufl3.ciency  of  the  interni  while  maintaining  full  ab- 
ducting power. 

She  has  been  seen  from  time  to  time,  and  careful 
observations  have  been  made  of  the  ocular  conditions 
as  well  as  of  her  general  health.     There  continues 


60  FUNCTIONAL  NERVOUS  AFFECTIONS. 

perfect  adducting  and  abducting  power,  and  the  equi- 
librium test  shows  no  insufficiency. 

Her  health  improved  from  the  time  of  the  opera- 
tions, the  color  returned  to  her  face,  she  gained  in 
weight  and  strength,  and,  although  a  year  has  passed, 
she  has  not  had  an  attack  of  migraine. 

The  results  of  treatment  of  migraine,  by  the  re- 
moval of,  or  assistance  to,  ocular  defects,  have  been  no 
less  successful  than  of  the  more  ordinary  forms  of 
headaches  by  similar  means  ;  but,  as  before  intimated, 
migraine  is  frequently  a  manifestation  of  more  com- 
plicated ocular  conditions  than  the  ordinary  head- 
ache, and  consequently  greater  care  in  discovering, 
and  greater  skill  in  removing,  these  defects  may  be 
demanded  in  this  than  in  the  more  ordinary  forms. 

It  is  a  fact  Avorthy  of  consideration  that  the  most 
violent  and  characteristic  symptoms  of  migraine  are 
directly  referable  to  the  orbit  or  its  immediate  sur- 
roundings. 

"We  may  well  suppose  that  the  i3aroxysm  repre- 
sents the  last  degree  of  perturbation  of  the  nerves  con- 
nected with  the  muscles  of  accommodation  or  of  con- 
sensual movements,  and  that  the  pain  in  and  about 
the  eye  and  the  intolerance  of  light  are  direct  manifes- 
tations of  this  condition  of  incomi)lete  surrender  of 
their  appropriate  functions. 

NEUEALGIA. 

Passing,  now,  to  the  consideration  of  neuralgia,  we 
shall  find  not  only  close  relations  with  the  forms  of 
neuroses  already  discussed,  but  that  difficulties  in  the 


NEURALGIA.  61 

performance  of  the  visnal  act  constitute  an  important 
causative  factor. 

Before  proceeding  to  discuss  tlie  tliera^Deutics  of 
the  disease,  it  will  be  well  to  determine,  first,  j)recisely 
w^hat  is  meant  by  the  word  as  used  in  this  essay,  in  or- 
der that  there  may  be  no  misunderstanding  as  to  the 
character  of  the  cases  which  may  be  adduced.  The 
word  neuralgia  (from  vevpov,  a  nerve,  and  d\yo<i,  a 
pain)  is  in  itself  almost  a  definition.  The  great  char- 
acteristic of  the  disease  is  pain,  which  is  located  usual- 
ly along  certain  nervous  trunks  or  their  branches,  not 
always  confined  to  their  perijDheral  distribution,  but 
often  following  the  whole  course  of  the  nerve.  A  sin- 
gle branch,  or  all  the  branches,  of  a  nerve  may  mark 
the  seat  of  pain.  In  its  character  it  is  usually  of  great 
intensity,  rather  sharply  defined  in  its  location,  re- 
mitting or  intermitting,  not  necessarily  attended  with 
any  vascular  excitement,  although  pyrexia  sometimes 
accomj^anies  the  paroxysm. 

Attacks  sometimes  commence  in  the  most  sudden 
manner.  The  patient,  engaged  as  usual,  possibly  in 
cheerful  conversation  or  in  laughing,  suddenly  feels  a 
stab  of  pain  dart  through  the  affected  part  as  though 
thrust  with  a  knife.  From  this  time  hours  or  days  of 
agonizing  torture  may  continue  with  more  or  less  re- 
mission, or  with  entire  intermissions.  Again,  the  i^ain 
is  first  manifested  as  a  dull  ache,  becoming  more  and 
more  acute  until  the  height  of  agony  is  reached.  The 
pain  is  described  as  cutting,  darting,  boring,  or  burn- 
ing, by  different  individuals,  and  all  grades  in  the 
impetuosity  of  the  attack  are  experienced,  from  the 


62  FUNCTIONAL  NERVOUS  AFFECTIONS. 

onset  of  dull  pain,  rapidly  increasing,  to  the  instanta- 
neous flash  of  agonj. 

The  general  health  during  the  intermissions  may 
suffer  little,  but  the  initial  attack  of  neuralgia  is 
usually  a  sequence  of  general  debility,  and  in  many 
instances  this  debility  continues  during  the  whole  his- 
tory of  the  disease.  While  some  sufferers  from  this 
complaint  are  ruddy  and  apparently  in  robust  health, 
others  are  exceedingly  anaemic  and  feeble  to  an  alarm- 
ing degree. 

The  presence  of  painful  points  during  the  inter- 
missions of  paroxysms  is  not  uniform  but  frequent. 
These  painful  points  may  be  along  the  course  of  the 
nerves  most  affected  or  not. 

Females  subject  to  chronic  neuralgia,  and  who 
suffer  from  anaemia  and  debility,  almost  always  experi- 
ence these  points  douloureux^  but  they  are  in  no  sense 
peculiar  to  neuralgia.  Indeed,  they  are  more  gener- 
ally associated  with  the  more  common  forms  of  head- 
ache already  described.  The  points  most  generally 
painful  are :  1.  At  the  spinous  process  of  the  first  or 
second  vertebra,  or  over  the  tendon  of  the  trapezius, 
on  a  plane  with  the  upper  vertebrae.  2.  Over  the  spi- 
nous process  of  the  seventh  cervical  vertebra ;  this  is 
by  far  the  most  frequently  painful  point  in  these 
cases,  and  it  is  very  often  associated  Tvith  pain  at  the 
lower  atagles  of  the  scapulae.  Although  not  an  in- 
variable rule,  it  may  generally  be  assumed  that,  if  the 
point  over  the  last  cervical  vertebra  is  painful,  pain 
will  also  be  found  at  the  lower  scapular  angles.  3. 
A  point  midway  between  these  last-named  positions. 


NEURALGIA.  63 

4.  At  the  junction  of  the  lower  lumbar  vertebra  with 
the  sacrum.  Other  points  less  frequent  are  at  the 
turn  of  the  shoulder,  and  a  point  below  the  middle  of 
the  clavicle.  These  i^oints  have  been  referred  to  in 
connection  with  headaches,  and  they  seem  to  indi- 
cate a  weakened  and  disturbed  state  of  the  nervous 
system.  They  are  often  found  in  cases  of  long-stand- 
ing chorea  and  in  epilepsy,  and  are  peculiarly  char- 
acteristic of  the  conditions  known  as  spinal  irritation 
and  neurasthenia.  They  are  sometimes  found  in  men, 
but  much  less  frequently  than  in  women.  The  pain  is 
not  imaginary,  as  some  believe,  but  is  often  a  source 
of  suffering  even  from  the  pressure  of  clothing. 

Intimately  associated  with  neuralgia  are  certain 
disturbances  of  nutrition,  as  shown  in  the  eruption  of 
herx^es  ;  and  of  motion,  as  illustrated  in  the  twitchings 
of  tic,  but  more  marked  convulsions  are  not  uncom- 
mon, and  paralyses  are  sometimes  observed. 

Yaso-motor  and  even  inflammatory  symptoms  are 
among  the  less  common  phenomena. 

Irradiation  of  pain  to  nerves  of  distant  parts  is 
one  of  the  interesting  characteristic  symptoms  of  neu- 
ralgia, as  it  has  an  important  bearing  upon  the  reflex 
nature  of  all  the  phenomena  of  the  complaint. 

Some  cases  of  neuralgia  run  their  course  quickly,  a 
single,  or,  at  most,  a  very  few  attacks  making  up  the 
history  of  the  complaint  so  far  as  this  iDeculiar  form 
of  neuroses  is  concerned.  Such  cases  recover  sponta- 
neously, or  under  the  influence  of  remedies  real  or 
supposed.  Other  cases  are  most  chronic,  continuing 
during  many  months  or  years,  and,  if  cured,  are  fre- 


64  FUNCTIONAL  NERVOUS  AFFECTIONS. 

qiiently  replaced  by  other  nervous  affections.  Still 
others  continue  during  the  life  of  the  patient. 

The  characteristic  group  of  symptoms,  therefore, 
which  represent  neuralgia  may  be  briefly  summed  up 
as  follows :  Pains  mostly  confined  to  the  course  or 
distribution  of  a  single  nerve,  most  frequently  of  one 
side,  and  of  unusual  violence. 

The  pain  is  intermitting,  or,  at  least,  usually  re- 
mitting, rarely  constant.  Certain  jDoints  in  the  course 
of  the  affected  nerve  are  generally  painful  on  press- 
ure, and  associated  with  the  affection  are  often  found 
painful  points  not  necessarily  in  the  affected  nerves, 
but  in  certain  localities  somewhat  uniformly. 

The  pain  is  also  frequently  associated  with  certain 
motor,  trophic,  and  sensory  phenomena. 

While  inflammatory  conditions  may  occasionally 
coexist,  inflammation  of  the  tissues  involved  in  the 
suffering  is  not  usual  or  in  any  way  characteristic. 

Yalleix  has  described  the  superficial  and  visceral 
groups  of  neuralgias,  and  has  minutely  described  the 
affection  in  each  specified  locality. 

It  is  not  within  the  scope  of  this  essay  to  describe 
these  various  forms  of  neuralgia,  of  which  it  may  be 
said  that  they  are  substantially  alike,  and  are  gov- 
erned by  almost  identical  influences.  They  are  all 
painful,  all  have  the  intermitting  or  remitting  charac- 
ter; in  each  variety  painful  points  may,  in  a  certain 
proportion  of  cases,  be  found  in  the  course  of  the 
affected  nerve  or  elsewhere,  and  in  each  anaesthesia 
of  the  skin  is  sometimes  found. 

It  is  important  to  note  that  these  various   forms 


NEURALGIA.  65 

are  more  or  less  intercliangeable,  in  some  instances 
more  so  than  in  others.  They  are  also  interchange- 
able with  other  neuroses. 

Many  persons  who,  during  several  years,  suffer 
from  migraine,  are  afterward  subject  to  facial  or  other 
forms  of  neuralgia. 

The  forms  of  neuralgia  are  often  spoken  of  as 
"protean,"  whereas  they  are  comparatively  uniform 
in  character,  differing  rather  in  respect  to  the  part 
affected  and,  as  above  stated,  quite  interchangeable. 

Including  in  this  discussion  only  the  forms  of  neu- 
ralgia which  may  be  called  idiopathic,  not  depending 
upon  trauma,  pressure  from  growths,  or  other  excep- 
tional causes,  it  can  not  be  said  that  there  are  any 
pathological  manifestations. 

"  liiTeuralgia  possesses  no  pathology,  if  by  that  word 
we  intend  to  signify  the  knowledge  of  definite  ana- 
tomical changes  always  associated  with  the  disease,  in 
a  manner  that  we  can  exhibit  or  exactly  describe," 
says  Anstie.* 

*' Neuralgia,"  says  Erb,  "must,  in  the  present  state 
of  our  knowledge,  be  regarded  as  a  symptom."  f 

Neuralgia  is  common  to  all  classes  of  society,  but  is 
more  prevalent  in  the  cultured  classes  than  in  others. 

A  great  variety  of  circumstances  may  act  as  im- 
mediate causes,  among  which  impoverished  circulation, 
draughts  of  cold,  or  excessive  physical  exertion,  are 
prominent.     These  and  other  immediate  causes  may  be 

*  Anstie  on  "  Neuralgia,"  etc.,  D.  Appleton  &  Co.,  New  York,  p.  140. 
t  Erb,  "  Diseases  of  Peripheral  and  Spinal  Nerves,"  "  Cyclopedia 
of  Practical  Medicine,"  vol.  xl,  p.  21. 


66  FUNCTIONAL  NERVOUS  AFFECTIONS. 

classified  as  causes  wliicli  reduce  tlie  total  amount  of 
nervous  energy,  and  we  are  to  inquire  why  such  agen- 
cies which  call  perhaps  for  only  moderate  expenditure 
of  nervous  energy  should  in  certain  individuals  induce 
such  serious  disturbances  while  in  others  they  produce 
no  appreciable  effect  ? 

The  answer  to  this  question  will  be  found  in  the 
fact  that,  in  those  predisposed  to  nervous  affections, 
there  is  a  constant  drain  upon  the  nervous  force  which 
exhausts  the  surj)lus  energy  to  such  an  extent  that  a 
demand  for  even  a  little  more  is  excessive. 

Let  us  suppose  the  neuralgic  patient  to  be  subject 
to  insufficiency  of  the  internal  recti  muscles,  and  to  be 
occupied  principally  in  work  requiring  the  use  of  the 
eyes  at  reading-distance.  There  is  an  unusual  demand 
upon  the  nervous  supply  required  to  stimulate  the 
muscles  of  adduction  to  perform  their  excessive  task. 
This  may  cause  no  local  suffering,  but  certainly  re- 
duces the  standard  of  nervous  energy.  Such  a  one 
may  be  able  to  generate  the  full  amount  of  force  neces- 
sary for  the  performance  of  all  the  ordinary  functions 
and  a  surplus  beyond ;  but  the  waste  that  occurs  in  the 
performance  of  a  single  function  exhausts  the  surplus, 
and  possibly  leaves  scarcely  enough  for  the  ordinary 
consumption. 

If,  now,  such  person  is  called  upon  for  some  unusual 
duty,  such  as  attendance  upon  a  sick  friend,  or  is  sub- 
ject to  unusual  emotional  shock,  the  effect  of  exhaus- 
tion of  nervous  energy  is  at  once  manifest,  and  an 
attack  of  neuralgia,  headache,  or  other  nervous  dis- 
turbance is  the  result. 


NEUEALGIA.  67 

The  effect  of  cold  is  to  cause  a  loss  of  the  little  re- 
serve nervous  energy  which  such  a  person  may  possess, 
and  also  if  the  effect  of  cold  is  ui^on  a  single  part  of 
the  body  to  cause  a  demand  for  a  readjustment  of  the 
disturbed  balance  of  nervous  energy. 

Such  a  waste  of  nervous  energy  as  we  have  sup- 
posed is  a  sufficient  cause  of  the  anaemia  which  is  sup- 
posed to  act  as  an  inducement  to  neuralgia,  and  again 
with  reduced  nervous  energy  there  may  be  disturbance 
or  delay  in  the  process  of  digestion  or  of  assimilation. 

Indigestion  and  anaemia  are  regarded  as  prolific 
causes  of  nervous  troubles,  but  they  are  themselves 
symptoms  and  generally  manifestations  of  the  same 
irritation  from  which  the  other  symptoms  arise. 

Let  us  still  suppose  our  case  of  insufficiency  of  the 
internal  recti  in  which  the  reserve  energy  is  unduly 
expended.  If  such  a  person  indulges  in  the  use  of 
certain  classes  of  food  or  too  much  food,  there  is  at 
once  an  increased  demand  for  nervous  force  ^yitll  which 
to  carry  on  the  now  unusually  difficult  function  of 
digestion.  Unless  this  is  furnished,  there  is  distress  in 
the  hypogastric  region  ;  but  if  it  is  furnished,  other 
disturbances  arise,  and  headache,  neuralgia,  or  even 
epilepsy  occur. 

Nerve- wounds,  foreign  bodies  or  tumors  pressing  in 
the  course  of  a  nerve,  or  other  mechanical  sources  of 
irritation,  may  act  as  original  and  independent  sources 
of  disturbance,  or  they  may  unite  their  inffuence  with 
a  more  j)ermanent  one. 

Anstie*  mentions  as  "one  of  the  most  powerful 
*  "  Neuralgia,"  1872,  p.  169. 


68  FUNCTIONAL  NERVOUS  AFFECTIONS. 

sources  of  periplieral  irritation  tending  to  set  up  neu- 
ralgia" the  "functional  abuse  of  the  eyes."  "This," 
he  says,  "is  one  of  the  very  few  peripheral  influ- 
ences which  occasionally  we  see  producing  neuralgia 
by  hereditary  predisposition." 

The  learned  writer  and  acute  observer  makes  little 
practical  account  of  what  he  evidently  regards  as 
among  causes  "altogether  accidental  and  factitious." 

If  we  inquire  to  what  extent  the  natural  or  ac- 
quired difficulties  in  performing  the  visual  act  influ- 
ence the  disposition  to  neuralgia,  we  shall  find  it 
very  great. 

Eight  hundred  and  fifty  cases  in  private  practice 
have  been  examined  with  reference  to  the  ocular  con- 
ditions, a  large  proportion  of  which  have  been  under 
observation  a  sufficient  time  to  enable  the  writer  to 
judge  of  the  result  of  treatment  in  this  direction. 

Without  attempting  to  make  an  analysis  of  the 
result  in  all  these  cases,  one  hundred  consecutive  cases 
are  selected,  as  in  the  class  of  cephalalgia,  as  fairly 
representative  of  the  whole  number. 

It  is  proper  to  add  that  these  were  all  typical  and 
chronic  cases  of  several  years'  duration.  Nearly  all 
were  people  of  ample  means,  who  had  spared  no  ex- 
pense in  their  endeavors  to  free  themselves  from  their 
malady.  Nearly  all  had  tried  the  virtues  of  drugs, 
baths,  and  electricity,  while  a  large  proportion  had 
spent  much  time  in  foreign  travel  and  in  seeking  for 
aid  at  celebrated  spas. 

Temporary  relief  had  generally  been  found  from 
some  of  these  means,   but  the  speedy  return  of  the 


NEUEALGIA.  69 

complaint  after  discontinuing  medical  treatment,  or 
after  returning  from  a  delightful  journey  amid  new 
and  interesting  scenes,  had  demonstrated  clearly  that 
the  relief  had  not  been  gained  by  the  removal  of  the 
radical  cause  of  the  evil. 

The  one  hundred  cases  selected  were  examined  be- 
tween the  dates  May  1,  1881,  and  August  30, 1882.  Of 
the  number,  twelve  were  not  subject  to  important  ocu- 
lar defects  or  were  not  seen  after  the  first  examination, 
and  may  be  rejected  from  this  present  inquiry.  Three 
placed  themselves  under  treatment  but  soon  discon- 
tinued without  accepting  the  advice  rendered  in  their 
cases. 

Eighty-five  were  treated  for  the  relief  of  unfavora- 
ble ocular  conditions  with  gi-eater  or  less  success  in  the 
correction  of  these  anomalies,  and  with  the  following 
results  relating  to  the  neuralgic  affection: 

Of  the  eighty-five  cases,  seventy-one  were  perma- 
nently relieved  of  neuralgia.  In  ten  cases  the  con- 
dition was  materially  improved,  but  entire  relief  was 
not  obtained,  while  in  four  cases  no  relief  was  gained. 

There  were,  then, 

Permanently  relieved 83 '53  per  cent. 

Materially  improved 11  "76        " 

N'ot  relieved 4'71        " 

100 
It  may  be  of  interest  to  study  the  condition  of  some 
of  those  where  no  relief  or  where  only  some  improve- 
ment was  obtained  ;  and  an  example  of  each  is  given. 
Mrs.  P.,  aged  forty-nine.    For  twenty  years  sub- 


70  FUNCTIONAL  NERVOUS  AFFECTIONS. 

ject  to  intense  neuralgia,  mostly  tri-facial.  Has  fre- 
quent fainting-tums,  and  is  in  many  respects  out  of 
health. 

Eight  eye  compound  myopic  astigmatism,  cor- 
rected by  a  glass,  spherical  2*25  D,  with  cylindrical 
1  D,  axis  180°. 

Left  eye  hypermetropic,  corrected  by  spherical 
+  1-25  D. 

There    is    homonymous    and   vertical    diplopia 
which  a  i^rism  of  8°  with  its  base  out,  and  another 
of  2°  with  its  base  down,  corrects,  at  a  distance  of 
twenty  feet,  uniting  the  images. 
With  a  full  understanding  on  the  part  of  the  pa- 
tient that  an  attempt  to  jDroduce  perfect  and  easy  bi- 
nocular vision  was  well-nigh  a  hoj^eless  task,  she  de- 
termined to  make  the  attempt  as  a  last  resort.     Glasses 
were  prescribed,  and  the  muscular  irregularities  so  far 
corrected  as  to  permit  binocular  vision,  but  the  vast 
difference  in  the  refractive  states  of  the  two  eyes  ren- 
dered the  attempt  to  produce  i^erfectly  united  action 
too  difficult.    Marked  temporary  improvement  in  the 
patient's  condition  followed  the  first  relief  to  the  diplo- 
pia, but  the  unj)leasant  symptoms  returned  after  about 
two  months. 

Every  oculist  will  recognize  the  difficulty  in  at- 
tempting to  induce  any  harmonious  action  between  so 
differently  constituted  organs,  and,  assuming  that  the 
neuralgia  was  the  outcome  of  the  ocular  errors,  the 
attempt  could  only  be  regarded  in  the  light  of  an  ex- 
periment. 

"Would  it  not  in  such  a  case  be  eminently  conserv- 


NEURALGIA.  71 

ative  to  remove  one  of  these  offending  organs  rather 
than  to  permit  all  this  suffering  to  continue  indefi- 
nitely ? 

The  next  case  shows  how  the  neuralgic  habit  may 
be  in  some  measure  modified,  while  some  of  the  im- 
portant ocular  defects  on  which  the  neuralgia  is  sup- 
posed to  depend  may  continue  : 

Mrs.  H.,  aged  forty-nine.  Subject  during  the 
past  nine  years  to  neuralgia.  Pains  located  along 
various  nerves.  Sometimes  manifesting  themselves 
as  sciatica,  at  others  as  cervico-brachial,  and  at 
others  as  still  different  forms  of  neuralgia. 

She  has  astigmatism  1-25  D,  with  insufficiency 
of  the  external  recti  muscles,  and  is  accustomed 
to  see  double  very  often.     There   is  well-marked 
mydriasis  of  the  left  eye,  a  condition  which  has 
existed  for  one  or  two  years. 
The  astigmatism  was  relieved  by  cylindrical  glasses, 
and  their  use  was  followed  by  a  very  marked  im- 
provement in  the  patient's  condition.     The  paresis  of 
the  accommodative    muscle,   however,   remains    as  a 
permanent  and  irritating  factor  for  which  there  is  no 
remedy. 

Hence,  while  a  certain  amount  of  relief  has  been 
secured,  complete  recovery  is  scarcely  to  be  hoped  for. 
Turning,  now,  to  the  more  successful  class  of  cases, 
it  will  be  seen  that  various  conditions  which  are  cal- 
culated to  create  difficulties  or  perplexities  in  the  use 
of  the  eyes  are  in  each  of  them  sufficient  to  induce 
the  phenomena  of  neuralgia  in  different  parts  of  the 
body. 


72  FUNCTIONAL  NERVOUS  AFFECTIONS. 

The  first  instance  which,  will  be  presented  illus- 
trates the  influence  of  enfeebled  accommodation  in 
contributing  to  the  production  of  neuralgia : 

Mrs.  S.,  after  the  birth  of  a  child,  in  1871,  suf- 
fered extreme  torture  from  crural  neuralgia.  This, 
after  a  few  months,  gave  place  to  neuralgia  of  the 
fifth  nerve,  while  many  manifestations  of  enfeebled 
health,  which  had  accompanied  the  first  form  of 
the  trouble,  continued  with  the  other.  Among 
these,  anseraia,  palpitation  of  the  heart,  and  dys- 
pepsia were  prominent.  She  continued  to  suffer 
from  these  troubles  with  slight  intermissions,  never 
knowing  a  month  of  freedom  from  severe  attacks, 
until,  in  the  summer  of  1874,  she  was  apparently 
reduced  to  the  last  extremity.  Notwithstanding 
all  that  could  be  done  by  a  change  of  residence  to 
a  deliglitful  home  in  the  country,  where  every 
advantage  of  excellent  air,  most  careful  nursing, 
and  distinguished  medical  attendance,  combined  to 
offer  every  hope  of  relief,  she  grew  steadily  worse. 
Her  face  was  colorless,  and  she  was  greatly  ema- 
ciated, the  heart's  action  was  extremely  irregular, 
her  strength  was  too  much  reduced  to  enable  her 
to  walk,  and  her  sufferings  from  pain  were  of  the 
most  intolerable  kind.  In  this  deplorable  and  al- 
most hopeless  state  she  was  removed  to  her  home 
in  the  city.  One  night,  while  in  extreme  agony,  a 
small  quantity  of  a  preparation  of  extract  of  Cala- 
bar bean  was  placed  on  the  conjunctivae  of  the  eyes 
as  a  forlorn  exj^eriment.  The  intense  pain  was  for 
a  moment  increased  to  exquisite  torture,  when  it 


NEURALGIx^.  73 

suddenly   ceased,  and  the  lady  fell  into  a  quiet 

slumber.      The   relief  so  happily  discovered   was 

followed  up  whenever  the  pain  returned,  for  a  few 

days,  after  which  there  was  no  longer  occasion  for 

its  use,  except  quite  rarely.      Strength  and  color 

quickly  followed,  and  health  was  rapidly  restored. 

In  this  lady's  case  there  was  in  one  eye  emmetro- 

pia,  while  in  the  other  there  was  myopic  astigmatism 

0*5  D.     This  slight  difference  in  the  refractive  state  of 

the  eyes  doubtless  acted  as  a  perj)lexing  cause  to  the 

muscles  of  accommodation  until   a  state  of  extreme 

irritability  had  arisen. 

Recognizing  the  permanent  nature  of  the  refractive 
states  and  the  liability  of  a  return  of  her  malady, 
especially  as  a  signal  to  any  unusual  cause  of  ex- 
haustion, she  has,  during  the  nine  years  which  have 
elapsed  since  the  first  use  of  the  Calabar  extract  al- 
ways kept  it  within  easy  access,  and,  when  warned  of 
any  return  of  her  trouble,  she  resorts  to  an  application 
of  a  minute  quantity  of  the  stimulant  to  the  eyes, 
with  the  effect  of  almost  instantaneous  relief.  By  this 
means  she  has  maintained  a  state  of  good  health,  and 
has  not  suffered  more  than  a  premonition  of  neuralgia 
at  any  time. 

The  following  case  not  only  shows  that  ocular  de- 
fects act  as  irritating  causes  to  distant  as  well  as 
proximate  nerves,  but  illustrates  the  effects  of  a  sec- 
ond of  the  perplexing  conditions  in  ocular  adjust- 
ments : 

Mrs.  F.  H.  D.,  aged  thirty-six.    Has  been  for 
many  years  a  victim  of  intercostal  neuralgia.     Has 


74  FUNCTIONAL  NERVOUS  AFFECTIONS. 

not  known  an  intermission  of  a  month  in  several 
years.  During  the  past  few  months  attacks  have 
occurred  i)retty  regularly  on  alternate  days.  Her 
physician  resorts  to  hypodermic  injections  of  mor- 
phine, often  repeating  the  injection  several  times 
during  the  same  night. 

The  eyes  were  examined  Angust  25,  1882,  and  she 
was  found  to  have  myopia,  right  1*50  D,  left  1-25  D, 
with  insufficient  power  of  adduction.  Glasses  for  the 
correction  of  the  myopia  were  adopted,  and  the  eyes 
exercised  daily  until  the  adducting  power  was  fully 
established. 

Her  last  attack  of  neuralgia  occurred  three  weeks 
after  the  first  effort  was  made  to  correct  the  ocular 
defects,  and  during  the  intervening  time  of  more  than 
a  year,  she  has  enjoyed  complete  immunity  from  pain 
and  perfect  health  in  all  resx)ects. 

InsuflBciency  of  the  external  recti  mnscles,  causing 
a  constant  demand  for  exertion  to  maintain  parallel 
visual  lines  when  looking  at  a  distance,  or  perplexity 
in  preventing  too  strong  convergence  when  the  eyes 
are  accommodated  for  near  points,  is  a  third  and  very 
frequent  cause  of  neuralgia. 

Miss  G.  M.,  aged  twenty-three,  has  been  during 
two  years  a  sufferer  from  facial  neuralgia.  The 
focus  of  pain  at  the  beginning  of  the  attack  is  at 
the  side  of  the  nose.  From  this  point  the  pain 
extends  to  the  face  and  temple  of  the  same  side. 
She  has  also  severe  dorsal  neuralgia,  and  much 
pain  at  the  lower  angles  of  the  scapulae.  During 
the  past  six  months  has  suffered  from  inability  to 


NEURALGIA.  75 

use  tlie  left  arm.  From  the  shoulder  downward 
there  is  marked  loss  of  power,  demanding  a  very- 
pronounced  effort  to  move  it.  The  leg  of  the  same 
side  suffers  similarly,  and  she  walks  with  a  very 
noticeably  halting  gait.  She  is  also  quite  dys- 
peptic. 

She  has  compound  myopic  astigmatism,  and 
says  that  she  has  double  vision  when  fatigued. 
There  is  insufficiency  of  the  external  recti  muscles 
of  4°  at  twenty  feet. 

The  myopic  astigmatism  was  corrected  by  glasses 
March  30,  1882.  The  neuralgic  attacks  were  modified 
but  not  cured,  and  on  the  4th  of  June,  1882,  tenotomy 
of  the  internal  rectus  of  the  left  eye  was  made.  The 
neuralgic  symptoms  disappeared  at  once,  the  limbs 
regained  their  usual  elasticity,  and  the  dyspepsia  gave 
her  no  further  trouble. 

October  4,  1883,  after  more  than  a  year  had  elapsed, 
she  called,  saying  that  she  had  been  entirely  well 
since  the  tenotomy,  but  that  within  a  few  days  there 
had  been  slight  returns  of  pain,  but  of  only  sufficient 
consequence  to  cause  her  to  inquire  into  the  condition 
of  the  eyes. 

All  modern  writers  on  neuralgia  agree  in  regarding 
it  as  an  hereditary  neurosis.  The  part  played  by  the 
hereditary  tendency  has  been  very  carefully  observed 
in  respect  to  its  various  manifestations,  as  exhibited 
in  different  individuals  of  families  in  which  the  com- 
plaint has  been  found. 

These  observations  have  resulted  in  showing  that 
in    families  in  which  neuralgia  exists  there  is    fre- 


76  FUNCTIONAL  NERVOUS  AFFECTIONS. 

qnently  not  only  a  tendency  in  tlie  blood  relations  of 
the  patient  to  neuralgic  affections,  but  to  a  large  class 
of  affections,  including  chorea,  insanity,  epilepsy, 
and  phthisis. 

The  nature  of  the  tendency  has  remained  a  mys- 
tery, the  question  of  direct  transmission  of  a  special 
form  of  disease  being  encountered  by  the  fact  that  it 
frequently  aj)pears  as  a  sequence  of  some  other  form 
of  neurosis. 

There  are  many  other  reasons  for  believing  that 
neither  neuralgia,  epilepsy,  nor  the  other  neuroses 
are  directly  transmitted  as  diseases,  and  it  is  believed 
that  the  evidence  about  to  be  brought  will  remove  all 
doubt  upon  this  subject. 

After  comparisons  of  the  family  history  and  physi- 
cal conditions  in  many  hundreds  of  instances  of  neu- 
roses, the  author  ventures  the  following  j^ropositions : 

1.  Hereditary  neuroses^  such  as  epilepsy^  mi- 
graine, neuralgia,  chorea,  and  insanity,  and  the 
same  principle  may  he  stated  to  hold  in  respect  to 
phthisis,  are  not  transmitted  from  parent  to  child 
directly. 

2.  Such  neuroses  are  the  manifestations  of  trans- 
mitted physical  peculiarities  .which  render  difficult 
the  performance  of  certain  important  functions. 

3.  That  of  the  hereditary  physical  defects  which 
thus  tend  to  develop  neuroses,  anomalous  conditions 
of  the  eyes  are  among  the  most  frequent  and  im- 
portant. 

Taking  in  my  hand  at  a  venture  a  book  of  records 
of  cases,  I  find  that  it  commences  January  1,  1878. 


NEUEALGIA. 


77 


Selecting,  now,  in  the  order  in  wMcli  they  occur,  ten 
consecutive  cases  of  neuralgia  in  which  the  family  his- 
tory has  been  written,  we  find  striking  evidence  in 
support  of  these  propositions.  It  should  be  said  in 
passing  that  in  the  pressure  of  work  the  family  his- 
tories of  many  cases  of  these  neurotics  have  not  been 
written,  hence  these  cases  are  not  literally  consecutive 
cases  of  neuralgia,  but  consecutive  cases  of  that  dis- 
ease, in  which  the  family  history  has  been  recorded : 

Table  showing  the  neuralgic  and  ocular  conditions  in  ten  suc- 
cessive cases  of  imj)ortant  neuralgic  affections,  xoith  the 
physical  condition  or  immediate  cause  of  death  among 
immediate  relations,  xcith  the  result  of  treatment  directed 
to  refractive  and  muscular  conditions  of  the  eyes. 


Results  of 

Form  and  dura- 

Physical condition  or  immediate 

treatment 

CASE. 

tion  of  neu- 

Ocular con- 

cause of  death  of  parents, 

directed  to 

ralgia. 

ditions. 

brothers,  and  sisters. 

ocular 
conditions. 

I. 

Supra-orbital, 

HtV, 

Father  (and   his  sister)  died  in- 

Perma- 

Lady, 

alternating 

insuf.  in- 

sane  ;  mother  has  chronic  neu- 

nent 

ac;ed 

with  migraine; 

terni. 

ralgia;    sister  a  nervous   in- 

relief. 

35, 

duration,  2 
years. 

valid. 

II. 

Facial  neural- 

n-iV. 

Father  and  mother  died  of  acute 

Not 

Lady, 

gia,  insomnia; 

diseases ;  one  sister  has  chron- 

known. 

aged 

duration. 

ic  neuralgia ;  of  a  brother  and 

28. 

many  years. 

sister  no  account  is  given. 

IIL 

Facial  and 

HTVH-AhJj, 

Father  died  of  phthisis  ;  mother 

Perma- 

Lady, 

cervico-bra- 

insuf.  ex- 

had    chronic    neuralgia ;    one 

nent 

aged 

chial ;  dura- 

tcrni. 

brother  chronic  neuralgia ;  one 

relief. 

46. 

tion,  15  years. 

has    epileptoid   vertigo;    one 
sister  strabismus. 

IV. 

Facial  ;   dura- 

Ahm jig. 

Father  and  mother  neuralgic ;  no 

Perma- 

Lady, 

tion,  4  years. 

brothers  or  sisters. 

nent 

aged 

40. 

relief. 

V. 

Cervico-bra- 

ASTiV, 

Father  asthmatic;   mother  was 

Perma- 

Gentle- 

chial, inter- 

insuf. ex- 

subject  to  migraine ;  a  brother 

nent 

man, 

costal,  etc. ; 

terni. 

died  of  cerebral  disease;  an- 

relief. 

aged 

duration,  20 

other  brother  and  four  sisters 

65. 

years. 

subject  to  migraine.  One  child 
of  the  patient  died  in  an  insane 
asylum,  and  three  other  chil- 
dren died  of  nervous  diseases. 

78 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


Table  shoioing  neuralgic  and  ocular  conditions  {continued). 


Results  of 

Form  and  dura- 

Physical condition  or  immediate 

treatment 

-CASE. 

tion  of  neu- 

Ocular con- 
ditions. 

cause  of  death  of  parents, 

directed 

ralgia. 

brothers,  and  sisters. 

to  ocular 

conditions. 

VI. 

Cervico-bra- 

M  ^  Am  tV^ 

Mother   and    two    sisters    have 

Perma- 

Lady, 

chial,  etc. ; 

insuf.  interni 

nervous  complaints ;  all  astig- 

nent 

aged 

duration,  2 

and  vertical 

matic  ;  father  well. 

relief. 

35. 

years. 

insuf. 

YII. 

Facial  neural- 

AhmJ-,. 

Father  subject  to  migraine  and 

Perma- 

Gentle- 

gia and  ceph- 

asthma;  mother  has  disease  of 

nent 

man, 

alalgia  ;  dura- 

the heart ;  a  brother  has  chron- 

relief. 

aqed 

tion,  many 

ic  headaches ;  another  suffers 

38. 

years. 

from  dyspepsia;  three  sisters 
are  nervous  invalids. 

VIII. 

Supra-orbital 

H^iV. 

Father  epileptic ;  mother  died  of 

Perma- 

Lady, 

neuralgia ; 

Blight's  disease;  a  sister  died 

nent 

aied 

duration,  10 

of  heart-disease ;  another  sister 

relief. 

56. 

years. 

has  chronic  neuralgia. 

IX. 

Dorso-inter- 

HA. 

Father  blind  and  a  hard  drinker; 

Perma- 

Gentle- 

costal;  dura- 

mother always  subject  to  mi- 

nent 

man, 

tion,  many 

graine;    a   sister    subject    to 

relief. 

aged 
55. 

years. 

spinal  irritation. 

X. 

Lumbo-dorsal 

n-A-, 

5Iother   always   subject    to   mi- 

Perma- 

Lady, 

neuralgia ; 

insuf.  in- 

graine ;  father  died  of  Bright's 

nent 

aged       duration,  5 

terni. 

disease ;  three  sisters  have  im- 

relief. 

24.            years. 

portant  nervous  disorders. 

Three  imjDortant  factors  characterize  this  list  of 
cases : 

1.  In  all,  the  hereditary  tendency  is  clearly  shown. 

2.  All  have  marked  refractive  and  muscular  anoma- 
lies, which  are  physical  features,  distinctly  hereditary. 

3.  The  uniform  relief  from  the  irritation  caused  by 
these  physical  peculiarities  proves  that  the  hereditary 
tendency  to  nervous  troubles  and  the  hereditary 
physical  peculiarities  were  in  these  cases  one  and  the 
same. 

It  is  distinctly  stated  that  the  ten  consecutive  cases 
above  quoted  do  not  materially  differ  in  their  signifi- 


NEURALGIA.  79 

cance  from  a  like  number  of  cases  taken  incidentally 
from  otlier  parts  of  the  records,  althongh  in  a  like 
number  the  same  projportion  of  marked  refractive 
lesions  might  not  always  prevail.  Should  a  greater 
number  of  consecutive  instances  be  selected  in  any 
part  of  the  whole  list,  the  teaching  would  be  practi- 
cally the  same. 

The  unmistakable  inference  to  be  drawn,  there- 
fore, from  the  study  of  a  great  many  cases,  is  that  the 
hereditary  tendency  to  neuralgia  is  quite  commonly 
found  in  the  physical  construction  of  the  eye  or  of  its 
appendages,  and  that  when  it  is  found  elsewhere  it 
may  be  regarded  as  in  a  degree  exceptional. 

In  assuming  this  inference  to  be  correct,  it  is  not 
necessary  to  ignore  known  facts  concerning  the  dis- 
ease, although  some  ancient  i)rejudices  may  possibly 
obtrude  themselves  in  opposition  to  it. 

This  inference  is  entirely  consistent  with  the  facts 
that  certain  influences  act  as  immediate  agents  in  in- 
ducing the  disease,  and  that  in  a  certain  j^roportion  of 
cases  other  permanent  conditions  may  be  quite  as 
active  as  causative  instrumentalities. 

It  is  also  consistent  with  the  fact  that  neuralgia  is 
a  complaint  which  most  frequently  makes  its  apj^ear- 
ance,  not  in  childhood,  when  the  tissues  are  most 
pliant,  and  when  the  effects  of  refractive  anomalies 
and  muscular  insufficiencies  can  be  most  easily  over- 
come, but  at  an  age  when  efforts  to  overcome  these 
difficulties  increase,  and  when  the  faculty  of  close  and 
critical  vision  is  brought  most  prominently  into  use. 

This  inference  is  also  notably  in  harmony  with  the 


80  FUNCTIONAL  NERVOUS  AFFECTIONS. 

fact  that  neuralgia  is  so  frequently  interchangeable 
with  migraine,  epilepsy,  and  insanity ;  for  we  have 
ah'eady  seen  that  visual  defects  are  most  im]portant 
factors  in  the  production  of  migraine,  and  we  shall 
find  that  it  is  scarcely  less  so  in  the  causation  of  other 
neuroses. 

It  is  manifestly  fallacious  to  presume  that  epilepsy 
and  neuralgia  are  convertible  diseases,  and  that  one 
can  be  directly  the  originator  of  the  other  by  inherit- 
ance or  by  any  necessary  sequence  in  the  same  indi- 
vidual. On  the  other  hand,  it  is  quite  reasonable  to 
supj)ose  that  a  common  cause  acting  upon  differ- 
ent individuals,  or  wpon  the  same  individual  at  differ- 
ent times,  may  give  rise  to  such  irritation  as  shall  be 
manifested  as  neuralgia,  epilepsy,  or  insanity,  depend- 
ing upon  the  resisting  strength  of  the  individual, 
upon  his  environment,  and  other  circumstances. 

By  accepting  such  a  view,  a  great  element  in  the 
doctrine  of  heredity  may  be  removed  from  the  realm 
of  mystery,  and  placed  in  the  domain  of  legitimate 
knowledge. 

In  order  that  the  inference  here  asserted  may  not 
be  misunderstood,  it  may  be  repeated  that  it  is  not 
claimed  that  ocular  defects  are  the  only  hereditary 
features  which  may  give  rise  to  neuralgia,  but  that 
they  are  pre-eminently  important. 

Incidental  causes  may  become  more  or  less  perma- 
nent according  to  their  nature,  and  induce  neuralgia 
or  other  neuroses  during  their  continuance. 

A  gentlemen  who  had  suffered  most  violent  facial 
neuralgia  for  many  months,  forcing  him  to  relinquish 


SPINAL  IREITATION  AND  NEURASTHENIA.        81 

his  business  and  to  seek  in  vain  relief  at  a  celebrated 
spa,  was  found  to  have  a  mass  of  hardened  cerumen  in 
the  ear.  The  removal  of  this  mass  was  followed  by 
instant  and  permanent  relief.  Many  instances  of 
which  this  is  a  fair  illustration  might  be  mentioned, 
but  they  constitute  no  such  general  class  that  the 
nature  of  the  cause  may  be  inferred  from  the  presence 
of  the  disease.  They  are  accidental,  and  should  al- 
ways be  sought  for. 

Such  instances  might  be  classified  with  those  aris- 
ing from  pressure  from  tumors  or  growths  and  from 
traumatic  causes. 

SPIiSTAL    lEEITATIOX    AND    NEUEASTHENIA. 

Closely  related  to  neuralgia  are  the  conditions  com- 
monly known  as  spinal  irritation  and  neurasthenia. 
They  are  characterized  by  general  loss  of  nervous 
energy  and  by  local  symptoms  more  or  less  complex ; 
certain  symjjtoms,  however,  prevailing  more  in  one 
than  in  the  other  form  of  nervous  disturbance. 

In  females  the  neuralgoid  pains  at  various  points  at 
the  neck,  back,  and  loins  are  wont  to  assume  much 
prominence  ;  great  weariness,  reduced  power  of  endur- 
ance, disinclination  or  even  disability  to  walk  or  to 
perform  any  physical  exertion,  increased  mental  irrita- 
bility and  disturbance  of  sensations,  all  go  to  consti- 
tute a  group  of  symptoms  quite  commonly  known  as 
"spinal  irritation"  ;  while  in  men  there  is  less  of  the 
neuralgic  element,  with  more  dull  pain  in  the  extremi- 
ties, or  general  sense  of  exhaustion,  inability  to  con- 
tinue at  office-work  where  writing  or  attention  to  ac- 


83  FUNCTIONAL  NERVOUS  AFFECTIONS. 

counts  is  required,  and  frequently  a  general  sense  of 
illness  whicli  i^revents  the  patient  from  following  his 
usual  avocation  or  even  confines  him  to  his  bed.  These 
cases  have  been  known  as  "neurasthenia." 

It  will  be  seen  that  females,  in  whom  there  are  usu- 
ally the  most  acute  sensibilities,  suffer  more  from  neu- 
ralgic symptoms,  while  men  are  more  affected  by  dull 
pains  and  hypochondria.  Unusually  sensitive  men  ex- 
hibit as  the  result  of  this  nervous  exhaustion  the 
group  of  symptoms  known  as  spinal  irritation,  while 
women  of  less  than  ordinary  susceptibility  to  acute 
impressions  have  neurasthenia. 

Allied  to  these  two  forms  of  nervous  troubles,  and 
to  a  certain  extent  including  them,  are  the  affections 
graphically  described  by  Marshall  Hall  as  "mimoses." 
These  are  characterized  by  weakness,  tremor,  head- 
ache, vertigo,  flutterings,  weariness,  pain,  and  tender- 
ness in  various  places,  constipation  and  hysteric  affec- 
tions. 

Attending  these  symptoms  are  also  frequently  ob- 
served loss  of  flesh,  decay  of  the  teeth,  chronic  pha- 
ryngeal affections,  and  a  morbid  state  of  the  gums. 

The  patient  has  cold  feet,  and  "  he  is  unaccounta- 
bly feeble  and  weary,  and  suffers  from  a  sense  of  ach- 
ing after  slight  exertion."  *  • 

The  name  "spinal  irritation"  implies  a  pathological 
condition  not  demonstrated  ;  and  the  division  of  these 
varieties  of  nervous  exhaustion  into  distinct  specific 
forms  is  at  least  doubtful.  The  name  applied  by  Mar- 
shall Hall  is  as  inclusive  and  as  fully  descriptive  as 
*  Marshall  Hall,  "  Mimoses,"  1823,  p.  22. 


SPINAL  IRRITATION  AND  NEURASTHENIA.       83 

either,  and  does  not  imply  any  theory  of  the  nature  of 
the  disease. 

It  is  not,  however,  the  aim  of  this  paper  to  discuss 
the  classification  of  diseases,  and  it  is  necessary  only 
in  this  connection  to  notice  the  fact  that  the  forms  of 
troubles  known  under  the  names  mimoses,  spinal  irri- 
tation, and  neurasthenia  are  simply  variations  in  the 
expression  of  a  chronic  waste  of  reserve  nervous 
energy — the  dex)leted  force  being  in  these  instances 
indicated  more  especially  as  weakness,  illy  defined 
pains,  and  general  nervousness,  than  in  specific  ex- 
plosions of  pain.  Here,  again,  we  see  the  result  of  a 
permanent  neuropathic  predisposition  or  cause  of  loss 
of  nervous  vigor,  and  here  we  shall  also  find  that  the 
loss  is  very  often  to  be  explained  by  the  unusual 
amount  of  force  exi)ended  in  j)erforming  the  visual 
function. 

A  few  examples  will  show  this  fact  more  clearly 
than  much  argument: 

Mr.  E.  N".,  aged  forty.  First  examined  March 
10,  1881.  Patient  is  a  tall,  well-built  man,  quite 
thin  and  sallow,  but  showing  no  indication  of  un- 
soundness of  internal  organs,  although  he  has  with- 
in a  week  been  assured  by  a  distinguished  prac- 
titioner that  he  has  Bright'S  disease  of  the  kid- 
.  neys.  Examination  of  the  urine  does  not  confirm 
this  diagnosis.  Eight  years  ago  he  began  to  ex- 
perience much  weakness  and  general  sense  of  ma- 
laise. Headache  commenced  about  the  same  time, 
and  has  been  an  important  symi^tom  during  the 
eight  years  of  his  disability.    The  headache  is  not 


84  FUNCTIONAL  NERVOUS  AFFECTIONS. 

constant,  but  occurs  after  efforts  at  reading  and 
writing ;  it  affects  the  top  of  tlie  head  mostly. 
Has  dull  backache,  and  a  feeling  of  stiffness  on 
bending.  Lower  part  of  the  back  habitually  sub- 
ject to  dull  pain.  He  is  quite  weak  ;  walks  with 
much  difficulty,  but  can  stand  and  walk  with  eyes 
closed.  There  is  a  general  sense  of  muscular  weak- 
ness and  dull  pain  in  the  legs.  Has  palpitation 
of  heart  after  walking  or  going  up-stairs.  Sleei^s 
poorly.  Appetite  variable.  Has  very  frequent  calls 
to  evacuate  the  bladder. 

He  has  been  obliged  to  surrender  his  business, 
and  has  for  some  years  devoted  himself  to  efforts 
to  restore  his  health.  To  this  end  he  has  several 
times  traversed  the  ocean,  twice  crossing  and  re- 
turning in  a  sailing-vessel.  While  at  sea,  he  is 
free  from  pain  in  the  head  and  back,  but  gains 
little  in  strength.  He  has  used  tonics,  electricity, 
baths,  and  a  great  variety  of  supposed  remedies, 
but  finds  nothing  but  a  sea- voyage  of  especial  serv- 
ice, and  the  symptoms  of  debility  return  rajDidly 
after  the  voyage  is  over. 

He  was  found  to  have  insufliciency  of  the  external 
recti  muscles,  and  partial  tenotomy  of  one,  and  soon 
afterward  of  the  other  internal  rectus  was  made.  Re- 
lief, very  marked  and  permanent,  quickly  followed.  The 
patient  returned  to  his  duties,  as  an  officer  of  a  large 
association,  very  soon  after  the  first  operation,  and  has 
continued  in  excellent  health  to  the  present  time ;  has 
gained  largely  in  flesh,  is  able  to  walk  as  well  as  oth- 
ers, and  has  no  headaches  or  pain  in  his  back  or  legs. 


NEURASTHENIA.  85 

The  following  case  of  typical  neurastlienia  is  equally 
typical  of  the  cases  described  by  Marshall  Hall  under 
the  name  mimosis : 

Miss  P.,  aged  forty.  Was  seen  by  request  of 
her  attending  jDhysician,  Dr.  Gault,  in  August,  1882. 
She  was  found  in  her  bed,  to  which  she  had  been 
confined  for  the  most  part  of  the  time  during  the 
past  three  years.  The  following  history  was  ob- 
tained :  The  X3atient  had  not  been  well  for  several 
years  before  resorting  to  her  bed,  but  being  a  per- 
son of  much  strength  of  character  had  exerted 
herself  to  continue  on  her  feet  as  long  as  possible. 
There  had  been  a  great  sense  of  weakness  and  in- 
ability to  use  her  limbs,  and  a  sense  of  fatigue  and 
dull  pain  in  the  lower  extremities.  There  was  also 
a  dull  ache  extending  from  the  neck  to  the  lower 
part  of  the  spine.  She  had  dull  pain  in  the  chest 
and  right  side  and  below  the  scapulae.  With  these 
a  dull,  generally  pervading  headache  was  a  very 
common  accompaniment. 

In  April,  1879,  she  resorted  to  her  bed,  which 
she  kept  during  more  than  three  years,  with  rare 
and  short  intervals,  when  she  was  able  to  leave  it 
for  a  few  days.  Such  intervals  of  improvement 
were  almost  always  followed  by  greater  prostration 
than  had  existed  for  some  time  before.  Especially 
was  this  the  case  if  any  attempt  to  walk  or  engage 
in  any  occupation  was  made. 
During  all  this  time  she  has  been  dyspeptic,  the 
stomach  refusing,  much  of  the  time,  to  retain  food, 
and  she  was  greatly  troubled  with  constipation,  subject 


86  FUNCTIONAL  NERVOUS  AFFECTIONS. 

to  cold  extremities,  palpitation,  and  general  sense  of 
extreme  weariness  ;  the  body  was  often  bathed  in  cold, 
oily  persi^iration.  The  nervous  irritability  was  so 
great  at  times  that  she  was  unable  to  listen  to  any  con- 
versation by  her  attendants  or  others.  She  became 
extremely  reduced  in  flesh  and  despondent  in  spirits. 

It  was  in  this  condition  that  she  was  found.  A 
significant  circumstance  observed  during  the  consulta- 
tion was  the  fact  that  during  the  conversation  she  lay 
with  the  forefinger  of  the  left  hand  closing  the  lids  of 
the  eye  of  that  side. 

A  subsequent  examination  of  the  eyes  showed  hy- 
permetropic astigmatism  1  D,  with  insuflBlciency  of 
the  external  recti  muscles. 

August  30th,  partial  tenotomy  of  left  internal  rectus 
was  made.  Sei^tember  3d  she  walked  upon  the  street 
nearly  the  distance  of  a  block.  September  26th,  her 
walks  had  been  extended  to  a  mile  and  a  half  daily. 
All  the  symptoms  of  nervous  prostration  were  greatly 
relieved,  but  she  still  spent  a  portion  of  the  day  in  bed. 

As  there  was  still  slight  insufficiency  of  the  ex- 
ternal recti  muscles,  tenotomy  was  very  carefully  re- 
peated, this  time  upon  the  right  eye. 

From  this  time  the  patient  continued  to  improve  in 
strength  and  endurance.  No  relapse  has  at  any  time 
occurred,  and  she  is  no  longer  dysx^eptic  nor  consti- 
pated, and  often  walks  two  or  three  miles  at  a  time. 

More  than  two  scores  of  cases  of  as  well-marked 
nervous  weakness  as  either  of  the  above  have  been 
under  observation  and  treatment  for  ocular  difficulties, 
with  equally  happy  results. 


CHOREA.  87 

Such  nervous  exhaustion,  when  it  is  the  result 
only  of  overwork,  speedily  disappears  when  the  pres- 
ence of  excessive  demands  upon  the  nervous  energies 
is  taken  off.  If  such  exhaustion  continues  as  a 
chronic  ailment,  there  is  evidence  that  there  is  a  per- 
petuating cause  which  should  be  sought  for  and  re- 
moved. 

These  conditions  of  nervous  weakness  are,  in  fe- 
males, often  attended  by  relaxation  of  some  of  the 
pelvic  muscles  and  ligaments ;  uterine  deviations  re- 
sult, and  perhaps  act  as  secondary  causes.  These 
secondary  causes,  themselves  symptoms,  are  frequent- 
ly treated  during  months  and  years  with  results  too 
well  known  to  the  medical  profession. 

CHOEEA. 

We  enter  upon  a  brief  examination  of  an  extreme- 
ly interesting  subject,  one  which  might  well  demand 
a  most  careful  and  extended  review.  It  is  proposed, 
however,  in  this  place,  only  to  call  attention  to  the 
bearing  of  some  of  the  most  characteristic  features  of 
the  disease  upon  the  subject  of  its  etiology  and  treat- 
ment. 

Notwithstanding  the  assertion  of  many  learned 
writers  that,  as  all  cases  of  chorea  are  chronic,  there 
can  properly  be  no  distinction  of  acute  and  chronic 
forms,  it  is  well  known  that  while  recovery  takes  place 
in  the  great  majority  of  cases  of  chorea  in  from  two 
to  four  months,  there  remains  a  certain  proportion  of 
cases  in  which  the  complaint,  resisting  all  medical 
treatment,  continues  many  years  or  a  lifetime. 


88  FUNCTIONAL  NERVOUS  AFFECTIONS. 

The  distinction  made  by  See  of  common  and 
chronic  chorea,  would  therefore  seem  a  practical  one. 

A  fact,  now  recognized  by  those  most  familiar  with 
the  common  form  of  chorea,  is  that  under  almost  all 
circumstances  recovery  takes  place  within  a  few  weeks 
after  the  onset.  Hence,  a  great  variety  of  remedies 
have  been  supposed  to  be  nearly  or  quite  specific  ;  and 
cases  are  reported  cured  by  cathartics,  by  bleedings, 
by  vermifuges,  and  cold  shower-baths,  as  well  as  by 
vegetable  tonics,  iron,  strychnia,  arsenic,  chloral,  and 
almost  numberless  so-called  remedies. 

It  is  an  interesting  fact  that,  in  defiance  of  such 
means  as  are  mentioned  in  the  first  part  of  the  fore- 
going list,  recovery  takes  place  almost  as  soon  as 
under  the  more  rational  tonic  treatment. 

In  the  chronic  form,  however,  there  are  no  spe- 
cifics ;  neither  cathartics  nor  tonics  do  much  if  any 
good,  and  the  patient  is  doomed  to  years  of  suffering 
and  perhaps  to  death,  for  death  not  infrequently 
comes  to  the  relief  of  these  unfortunate  sufferers, 
while  the  physician  consoles  himself  with  the  un- 
founded dictum  that  the  disease,  being  based  upon 
chronic  lesions  of  the  brain  or  spinal  chord,  is  there- 
fore incurable. 

That  anatomical  lesions  of  the  brain  or  of  the  cord 
are  sometimes  coincident  with  chronic  chorea  it  is 
true,  but  that  there  is  necessary  or  causative  relation 
between  the  two  conditions  has  not  been  shown.  In- 
deed, it  is  much  more  probable  that  the  anatomical 
lesions  of  the  brain  and  cord  are  among  the  results  of 
chorea  or  of  the  irritation  causing  it,  and  that  they 


CHOEEA.  89 

are  not  in  in  any  respect  tlie  original  sources  of  irri- 
tation. 

In  considering  the  interesting  fact  that  so  many- 
cases  of  "choree  vulgaire"  recover  under  so  many 
I'adically  different  methods  of  treatment,  the  age  of 
the  patients,  and  the  circumstances  attendant  npon  the 
period  of  life  at  which  the  great  majority  of  cases 
occur,  must  be  regarded  as  an  important  factor  in  ex- 
planation of  the  circumstance. 

Dr.  P.  H.  Pye-Smith  found  that  of  136  choreic  pa- 
tients at  Grey's  Hospital,*  106  were  between  the  ages 
of  six  and  fifteen,  and  62  of  these  were  between  the 
ages  of  six  and  ten.  In  other  words,  nearly  half  were 
at  the  age  when  children  enter  schools,  and  nearly  all 
were  children  of  school  age. 

Researches  of  the  author  of  this  essay  prove  that 
the  .majority  of  cases  of  chorea  occur  among  children 
who  are  hypermetropic.  If  we  consider  that  the 
strain  upon  the  muscle  of  accommodation  in  these 
hypermetropic  children  is,  during  the  first  years  of 
school-life,  an  unusual  one,  and  that  the  attending 
confinement  and  possibly  impure  air  of  schools  may 
aggravate  the  effect  of  the  excessive  demand  upon  the 
accommodation  in  delicate  children,  it  will  not  be 
difficult  to  see  that  great  nervous  disturbance  may 
result. 

Now,   npon  the  advent  of  decided  symptoms  of 

chorea,  the  child  is,  in  the  great  majority  of  instances, 

at  once  remolded  from  scTiool.    The  strain  upon  the 

overtaxed  accommodation  is  relieved,  and  in  the  space 

*  "  Grey's  Hospital  Eeports,"  third  series,  xix,  p.  341. 


90  FUNCTIONAL  NERVOUS  AFFECTIONS. 

of  a  few  weeks,  as  soon  as  time  lias  been  allowed  for 
the  overtaxed  muscle  to  regain  its  tone,  the  child  re- 
covers from  chorea,  in  defiance  of  medicines  or  possi- 
bly assisted  by  them. 

An  important  symptom  of  chorea  may  also  be  di- 
rectly explained  on  this  hypothesis.  It  is  well  known 
that  widely  dilated  pupils,  reacting  feebly  in  response 
to  the  influence  of  light,  constitute  a  very  character- 
istic feature  of  this  complaint,  and  it  has  also  frequent- 
ly been  observed  that  on  the  termination  of  chorea 
the  dilatation  of  the  pupils  disappears.  Dilatation 
of  the  pupils  is  not  always,  but,  as  a  rule,  associated 
with  enfeebled  accommodation,  and  may  be  regarded 
as  indicating  weakness  of  the  ciliary  muscle  in  j^ro- 
portion  to  the  degree  of  mydriasis.  An  example  is 
found  in  paralysis  of  the  third  nerve,  when  the  pupil 
is  widely  dilated  and  accommodation  nearly  or  quite 
suspended. 

Returning  to  the  condition  of  the  pupil  in  these 
choreic  children,  a  great  proportion  of  them  are 
hyi^ermetropic.  They  have  not  been  accustomed  to 
the  continued  act  of  accommodation,  and  when  sent 
to  school  or  put  to  any  other  close  work  where  a  very 
marked  and  continued  effort  to  maintain  accommoda- 
tion is  required,  the  ciliary  muscle  experiences  fatigue 
and  finally  exhaustion,  its  action  is  considerably  en- 
feebled, and  with  it  the  action  of  the  sphincter  pupi- 
Ise.  The  widely  dilated  pupil  is  the  signal  which  tired 
K'ature  gives  as  a  warning  to  discontinue  overwork  of 
the  exhausted  muscles.  If  the  signal  passes  unheeded, 
the  whole    nervous  system    surrenders.     "When    the 


CHOREA.  91 

cliild  is  withdrawn  from  scliool,  or  other  emiDloyments 
wMch  require  the  use  of  the  eyes  at  close  range  (for 
many  of  these  children  are  from  among  the  poor,  who 
demand  a  certain  amount  of  labor  even  from  the  very 
young),  the  wearied  muscle  gradually  regains  its  con- 
tractile power,  and  the  pui^il  returns  to  its  normal 
state. 

Hence  we  may  justly  reverse  the  statement  made 
above,  that  the  dilatation  of  the  pupil  disappears  on 
the  termination  of  chorea,  and  say  that  with  the 
proper  contractile  power  of  the  ciliary  muscles  nervous 
quiet  is  restored. 

In  reply  to  this  line  of  argument  may  be  adduced 
the  fact  that  many  children  and  even  adults  with  di- 
lated pupils  do  not  have  chorea.  To  which,  again,  it 
may  be  replied  that  not  all  similar  causes,  acting  upon 
different  individuals,  produce  like  effects. 

It  has  been  stated  that  observations  have  shown 
that  the  majority  of  cases  of  chorea  occur  among 
hyiDermetropic  children.  Of  118  cases  examined  in 
private  practice — 

Simple  hypermetropia  existed  in 78 

Hyj)ermetropic  astigmatism  existed  in 13 

Mixed  astigmatism  in 5 

Myopia,  unequal  in  the  two  eyes,  in 6 

Mj^opic  astigmatism  in 11 

Associated  with  these  conditions  in  a  considerable 
number  of  the  above  cases,  more  or  less  muscular  disa- 
bility was  found. 

Insufficiency  of  the  lateral  recti  muscles,  with  no 
marked  degree  of  refractive  error,  existed  in  five. 


92  FUNCTIONAL  NERVOUS  AFFECTIONS. 

It  will  be  seen,  therefore,  that  if  ocular  irritation 
is  admitted  to  be  a  factor  in  chorea,  hYi)ermetroi)ia 
must  play  an  important  role.  It  can  be  easily  under- 
stood, then,  why  chorea,  in  the  ordinary  cases,  ceases, 
as  does  asthenopia,  but  somewhat  less  promptly,  upon 
discontinuance  of  the  use  of  the  eyes  for  close  work. 

Hence,  also,  it  will  be  seen  that  he  who  treats  a  few 
cases  of  chorea  in  a  special  way  is  likely,  if  the  child  is 
in  each  instance  withdrawn  from  school,  to  witness  a 
cure  ;  and  thus  he  comes  to  regard  the  agent  employed 
as  the  curative  means,  whereas  in  fact  the  rest  was  the 
actual  curative  agency. 

Manifestly  statements  of  cure  based  ui)on  the  class 
of  cases  which  may  be  called  acute,  must  be  comi^ara- 
tively  of  little  weight,  as  they  may  bear  no  relation  to 
the  influence  of  the  supposed  remedy. 

N'evertheless,  the  experience  of  many  of  the  best 
observers  goes  to  prove  that,  on  the  whole,  cases  re- 
cover more  quickly  under  the  influence  of  tonic  reme- 
dies than  otherwise.  Notwithstanding  the  somewhat 
definite  termination  of  chorea  in  recovery,  it  is  true 
that  in  after-life  a  great  many  of  those  who  have  been 
victims  of  the  complaint  suffer  from  some  other  form 
of  neurosis.  It  would  be  impossible  to  say  to  what 
extent  this  statement  holds  without  tracing  the  history 
of  a  considerable  number  of  cases  through  several 
years.  The  statement  is  based  not  only  upon  the  ob- 
servations of  many  writers,  but  upon  a  considerable 
number  made  by  the  writer,  in  which  he  has  learned 
that  patients,  who  in  adult  life  suffered  from  epilepsy, 
neuralgia,  and  headache,  were  in  childhood  subjects  of 


CHOREA.  93 

chorea.  And  it  has  also  been  observed,  in  several  of 
these  cases,  that  a  sujDiDOsed  cure  of  chorea  has  been 
only  a  change  to  chronic  headache,  or  other  neurosis. 
Passing  to  the  less  hopeful  class  of  cases,  those  of 
the  more  chronic  form,  the  results  of  treatment,  if 
favorable,  may  be  regarded  as  significant.  If,  after 
several  years  of  suffering,  relief  follows  uniformly 
upon  the  employment  of  certain  remedial  measures, 
and  if  the  disease  is  not  replaced  by  another,  it  is  quite 
legitimate  to  suppose  that  the  remedial  measures  have 
been  directed  to  the  true  cause  of  the  complaint. 

After  careful  study  of  the  cases  which  have  been 
examined,  and  treatment  of  many  of  them  for  the  re- 
moval of  ocular  anomalies,  the  author  does  not  hesitate 
to  assert  the  direct  relation  between  these  ocular  diffi- 
culties and  the  disease  in  question. 

The  study  of  the  cases  which  are  here  adduced  can 
not  fail  to  confirm  this  assertion.     These  cases  are 
selected  as  being  in  all  respects  representative  of  the 
class  of  chronic  cases  generally  supposed  to  have  their 
origin  in  some  anatomical  lesion  of  the  nervous  centers. 
They  are  all  typical  in  respect  to  the  general  mus- 
cular irregularities,  all  accompanied  by  marked  mental 
effects,  all  exceedingly  chronic,  and  each  has  received 
the  benefit  of  continued  and  able  medical  attendance. 
Mr.  E.  L.  D.,  aged  thirty.     First  seen  July  13, 
1882.    When  about  ten  years  of  age  began  to  have 
chorea.     The  cause  was  supposed  to  be  a  slight 
injury  to  the  head  received  some  weeks  before  the 
advent  of  choreic  symptoms.     The  disease  has  run 
a  pretty  uniform  course  during  twenty  years. 


94  FUNCTIONAL  NERVOUS  AFFECTIONS. 

He  now  has  the  characteristic  jerkings  of  the 
face,  legs,  and  arms ;  twitchings  of  the  abdominal 
muscles  are  among  the  most  constant  and  unpleas- 
ant of  the  choreic  disturbances.  He  appears  lan- 
guid, and  says  that  he  is  always  tired.  He  is  thin 
in  flesh,  draws  his  legs  in  walking,  sleeps  irregu- 
larly, has  headache  much  of  the  time,  and  for  ten 
years  past  has  experienced  all  the  troublesome 
symptoms  of  asthenopia. 

His  circumstances  have  been  such  as  to  permit 
him  to  employ  whatever  means  offered  a  reasonable 
hope  of  relief,  but  every  attemj^t  has  met  with 
failure. 

I  find  hypermetroi)ia  1'25  D,  with  insufficiency 
of  the  external  recti  muscles. 
Convex  glasses  were  prescribed  for  constant  use, 
and  on  the  24th  of  July,  1882,  tenotomy  of  the  right 
internal  rectus  muscle  was  performed,  apparantly  re- 
storing the  equilibrium  of  the  lateral  muscles.  A 
marked  improvement  in  his  symptoms  commenced  at 
once.  Within  the  next  two  weeks  the  choreic  symp- 
toms were  scarcely  noticeable,  and  he  no  longer  suf- 
fered from  headache.  He  was  seen  a  month  later,  still 
gaining  in  flesh,  strength,  and  spirits,  and  on  the  18th 
of  August,  1883,  he  called,  in  passing  through  the  city, 
to  report  his  condition.  He  seemed  in  perfect  health, 
had  no  choreic  symptoms,  had  gained  much  in  weight, 
and  declared  that  he  had  no  recollection  of  a  year  of 
such  complete  health  as  he  had  enjoyed  during  that 
which  had  Just  passed. 

Miss  K.,  aged  nineteen,  came  in  April,  1879,  by  the 


CHOREA.  95 

advice  of  her  physician,  Dr.  L.  B.  IN'ewtoii,  of  North 

Bennington,  Vermont. 

Has  had  chorea  nine  years.  The  malady  first  ex- 
hibited itself  in  twitchings  of  the  eyelids  and  gen- 
eral restlessness,  while  attending  school.  To  this 
condition,  twitchings  and  contortions  of  the  limbs 
soon  succeeded,  but  she  was  not  removed  from 
school  until  the  symptoms  became  so  violent  that 
she  could  no  longer  attend. 

To  the  violent  muscular  disturbances  were  added 
severe  and  almost  constant  headache. 

Choreic  disturbances  and  headache  have  con- 
tinued during  the  nine  years  with  no  important 
remission.  The  i)atient  is  exceedingly  low-sx^irited 
and  feeble,  has  the  look  of  utter  despondency,  is 
unable  to  attend  to  any  employment  or  to  amuse 
herself  with  books.  As  she  sits,  her  head  is  con- 
tinually drawn  by  powerful  and  sudden  muscular 
contractions  toward  the  right  shoulder,  a  movement 
effected  every  few  seconds,  and  apjDarently  accom- 
panied by  mental  and  physical  suffering.  The 
hands  and  feet  twitch  incessantly,  and  the  facial 
muscles  are  rarely  at  rest. 

Against  this  distressing  condition  of  mind  and 
body  she  has  employed  such  means  as  able  physi- 
cians have  advised,  with  entirely  negative  results. 
She  was  found  to  have  a  moderate  degree  of  myopic 

astigmatism,  with   insufficiency  of  the  internal  recti 

muscles. 

Cylinders  for  the  correction  of  the  astigmatism  were 

prescribed,  and  a  month  later  tenotomy  of  one  of  the 


96  FUNCTIONAL  NERVOUS  AFFECTIONS. 

external  recti  muscles  was  made.  The  oi)eration  was 
followed  by  exercises  of  the  ocular  muscles  by  the  aid 
of  prisms  for  some  days  until  a  good  degree  of  flexi- 
bility of  all  the  muscles  was  obtained. 

The  health  of  the  patient  commenced  to  improve 
rapidly  from  the  time  of  the  tenotomy,  and  within  a 
few  weeks  her  health  was  in  all  resi)ects  restored.  She 
has  been  seen  from  time  to  time  during  the  interval  of 
more  than  four  years,  and  on  all  occasions  she  exhibits 
physical  and  mental  conditions  in  most  marked  con- 
trast to  those  which  formerly  existed.  Her  face  has 
the  glow  of  health.  She  is  well  nourished,  walks  with 
elastic  step,  has  no  headache,  and  is  in  the  enjoyment 
of  all  the  hopes  and  happiness  natural  to  one  of  her 
age. 

Miss  J.,  aged  fourteen.  Came  with  a  letter  from  her 
physician.  Professor  A.  T.  Woodward,  March  14,  1883. 
Has  had  chorea  for  rather  more  than  a  year. 
Has  muscular  twitchings  in  limbs  and  body,  is  ex- 
ceedingly restless,  and  is  in  a  peculiar  and  unfortu- 
nate mental  condition.  She  is  willful  and  stub- 
born, morose  and  unreasonable.  She  escapes  from 
her  attendants  when  walking,  and  often  hides  her- 
self. Her  speech  is  slow,  her  voice  monotonous 
and  dragging.  Dementia  is  the  term  which  most 
clearly  exjDresses  her  intellectual  state.  She  is  pale, 
thin,  and  weak.  There  is  no  evidence  of  disease  of 
the  heart  or  of  any  internal  organ. 

Examination  of  the  eyes  shows  that  she  has 
hyi)erme tropic  astigmatism  "75  D,  and  that  the 
ocular  muscles  have  but  feeble  associating  force. 


CHOREA.  97 

Addiicting  power  at  twenty  feet,  8°  ;  abducting,  2°. 
By  exercising  tlie  eyes  for  a  few  minutes  daily  with 
prisms,  the  adducting  power  in  the  course  of  two 
months  rose  to  35°,  and  the  abducting  power  8°, 
She  had,  in  the  mean  time,  made  use  of  cylindrical 
glasses  for  the  correction  of  her  astigmatism. 

Her  health  imi)roved  in  proportion  as  the  flexibility 
of  the  ocular  muscles  increased,  and  she  went  away  at 
the  end  of  two  months  much  better  in  aU  respects 
than  when  she  came. 

October  20th,  after  nearly  five  months,  she  calls 
with  her  mother.  She  is  in  perfect  physical  and 
mental  health.  She  shows  no  indicrttion  of  nervous- 
ness, is  rosy,  and  has  a  bright,  intelligent  expression ; 
speaks  quickly  and  without  monotony,  and  is  in  all 
respects  a  healthful,  intelligent,  and  tractable  child. 

Master  I.,  aged  thirteen  years.  Came  attended  by 
his  physician,  Dr.  P.  H.  ISTeher,  October  30,  1879. 

The  patient  has  been  the  subject  of  chorea  nine 
years,  during  which  time  he  has  been  under  the 
charge  of  several  distinguished  physicians,  who 
have  treated  him  by  tonic  medicines,  including 
preparations  of  iron  and  arsenic,  strychnine,  and 
other  medicines.  Electricity  and  change  of  cli- 
mate have  also  been  among  the  means  through 
which  relief  has  been  sought,  but  not  obtained. 

His  condition  at  the  present  time  is  deplorable, 
although  not  worse  than  usual  with  him.  The 
muscular  contractions  are  most  violent,  and  extend 
to  all  parts  of  the  body.  It  is  with  great  difficulty 
that  he  can  sit  in  a  chair,  as  the  body  is  thrown 


93  FUNCTIONAL  NERVOUS  AFFECTIONS. 

about  so  violently  as  to  dislodge  him  from  his  seat. 
Even  while  sitting  the  legs  are  thrown  in  all  direc- 
tions, and  his  head  strikes  the  back  of  the  chair 
with  frequent  and  energetic  thumps. 

"When  walking,  the  legs  become  entangled,  and 
the  head  is  thrown  backward  with  the  greatest 
violence.  "With  much  difficulty  the  condition  of 
the  eyes  was  determined. 

He  was  found  to  have  hypermetropic  astigmatism 
and  insufficiency  of  the  externi,  with  insufficient  ad- 
ducting  energy,  the  latter  being  sufficient  only  to  over- 
come a  jjrism  of  6°. 

The  astigmatism  was  corrected  by  cylindrical  glass- 
es, and  the  adducting  j)ower  exercised  until  it  was 
greatly  increased. 

"When,  at  the  end  of  two  weeks,  his  physician 
called  to  see  him,  he  was  amazed  at  the  change  that 
had  come  over  the  lad.  He  was  now  able  to  walk 
with  regular  and  even  steps,  could  sit  in  his  chair  at 
ease,  and,  indeed,  appeared  well.  With  some  vary- 
ings  in  his  condition  which  could,  in  all  cases,  be  asso- 
ciated with  equally  varying  conditions  of  the  eye- 
muscles,  he  recovered  rapidly,  and,  with  the  excep- 
tion of  occasional  slight  twitchings,  has  remained  well 
during  the  four  years. 

Miss  M.,  fifteen  years  of  age,  examined  November 
27,  1881. 

Eight  years  ago  had  chorea,  which  has  con- 
tinued to  the  present  time.  There  are  facial  con- 
tortions, shrugging  of  the  shoulders,  and  general 
restlessness.     She  is  well  nourished  and  finely  de- 


CHOEEA.  99 

veloped,  is  intellectually  bright,  and  at  times  cheer- 
ful. 

There  is  a  murmur  with  the  first  sound  of  the 
heart,  but  no  other  evidence  of  organic  disease. 

During  the  eight  years  there  have  been  periods 
of  a  few  weeks  when  there  has  been  slight  remis- 
sion of  the  symptoms,  but  they  have  never  at  any 
time  disappeared.  She  is  better  if  she  avoids 
books  and  keeps  much  in  the  open  air. 

She  has  astigmatism  of  low  grade  and  insuffi- 
ciency of  the  internal  recti  muscle   6°  at  twenty 
feet ;  7°  at  one  and  a  half  foot. 
Early  in  February,  1882,  tenotomy  of  one  external 
rectus  was  made  and  three  weeks  later  of  the  other. 
Improvement  in  the  nervous  state  followed,  and  entire 
recovery  within  a  few  months. 

During  the  past  two  years  she  has  pursued  her 
studies  abroad,  and  I  learn  from  a  letter,  vsritten 
within  the  past  month,  that  she  is  still  quite  well. 

[The  two  portraits  shown  in  Plate  II  are  those  of  an 
interesting  case  of  chorea  which  had  continued  during 
the  lifetime  of  the  patient,  a  boy  of  sixteen.  The  boy 
was  feeble-minded  and  incapable  of  learning.  His 
whole  body  was  in  perpetual  motion.  This  is  well 
shown  in  the  photograph,  taken  April  28th,  when,  not- 
withstanding the  rapidity  of  modern  photography,  it 
was  quite  too  slow  to  get  a  clear  picture.  The  shaded 
borders  of  the  picture  show  the  movements  of  the  head. 
The  boy  had  hyperopia  2*50  D.,  and  insufficiency  of 
the  interni,  to  the  extent  of  producing,  much  of  the 
time,  homonymous  diplopia,  which  was  shown  when  a 


100  FUNCTIONAL  NERVOUS  AFFECTIONS. 

red  glass  was  placed  before  one  of  Ms  eyes,  the  refract- 
ive error  being  first  corrected.  Tenotomy  of  tlie  left 
internus  was  done,  April  28,  1885,  and  of  the  right  on 
the  6th  of  May  following. 

The  change  in  the  boy's  condition  was  marvelous. 
The  two  portraits  do  not  exaggerate  the  improvement, 
nor  do  they  even  adequately  represent  it.  He  has  had 
no  chorea  during  the  two  years  which  have  iDast.  He 
has  attended  school,  where  he  has  made  some  progress 
in  his  studies,  and  is  in  every  respect  mentally  and 
physically  greatly  improved.*] 

Many  cases,  of  which  those  ali'eady  described  are 
fair  examples,  might  be  adduced  to  prove  the  rela- 
tions between  those  long-continued  cases  of  chorea 
and  irritations  attributable  to  the  eyes.  It  is  need- 
less, however,  to  accumulate  evidence  of  this  kind  be- 
yond what  has  already  been  offered. 

It  can  not  be  doubted  that  the  relief  so  speedily 
obtained  in  these  cases  not  only  followed  the  treat- 
ment directed  to  the  eyes,  but  that  this  improve- 
ment was  the  legitimate  result  of  such  treatment. 

If,  then,  refractive  and  muscular  troubles  of  the 
eyes  are  so  generally  found  associated  with  chorea, 
and  if  cases  which  may  justly  be  regarded  as  belong- 
ing to  the  class  heretofore  regarded  as  incurable,  are 
able  to  obtain  such  speedy  and  complete  relief  as  is 
shown  in  the  cases  described,  may  we  not  conclude 
that  chorea  is  emphatically  a  nervous  trouble  de- 
pending upon  ocular  conditions? 

*  This  case,  not  in  the  original  essay,  is  introduced  here  on  account 
of  the  accompanying  portraits  of  Plate  II. 


EPILEPSY.  101 

That  irritations  seated  elsewhere  may  cause  the 
disease,  is  not  to  be  denied. 

Especially  may  irritations,  proceeding  from  differ- 
ent parts  of  the  body,  act  as  immediate  or  as  compli- 
cating causes,  but  it  is  probable  that  cases  which 
occur  without  any  relation  to  ocular  difficulties  are 
rare  exceptions  to  a  very  general  rule. 

The  indications  for  the  treatment  of  chorea  are 
evident  if  the  general  nature  of  the  cause,  as  shown, 
is  admitted.  Children  with  the  first  symptoms  of 
^^ choree  Dulgaire^''  must  be  at  once  removed  from 
school,  and  from  aU  occupations  demanding  the  use 
of  the  eyes.  General  tonic  remedies,  fresh  air,  and 
agreeable  surroundings  may  all  prove  valuable  as  _ 
auxiliaries  in  the  treatment  of  these  cases.  The  use 
of  a  weak  solution  of  eserine  applied  to  the  eyes  once 
or  twice  a  day  will  often  serve  as  a  valuable  temporary 
expedient. 

The  child  should  not  be  returned  to  school  with- 
out an  examination  of  the  eyes  in  regard  to  their  re- 
fractive and  muscular  states.  In  chronic  cases  the 
cause  should  be  sought  for  in  the  eyes.  If  not  found 
there,  at  least  a  very  jjrobable  seat  of  trouble  will 
have  been  explored. 

EPILEPSY. 

The  course  of  this  discussion  now  leads  us  to  con- 
sider one  of  the  most  important  as  well  as  one  of  the 
most  mysterious  of  all  the  affections  of  the  nervous 
system.  A  disease  dreadful  in  its  manifestations,  and 
well-nigh  hopeless  in  its  prognosis,  nearly  always  un- 


102  FUNCTIONAL  NEEVOUS  AFFECTIONS. 

fitting  its  victims  for  useful  employment  or  enjoyment 
during  its  early  periods,  it  generally  robs  tliem  of  in- 
tellect and  reason  in  the  end. 

Any  additional  knowledge  of  this  fearful  malady 
must  prove  a  valuable  contribution  to  science,  if  it  can 
be  made  available  for  the  relief  of  any  proportion  of 
its  victims. 

For  the  purposes  of  this  discussion  the  form  of 
epilepsy  only  which  does  not  depend  upon  visible 
anatomical  lesions  is  to  be  considered. 

It  has,  of  course,  no  "pathology,"  so  far  as  the 
description  of  physical  alterations  of  structure  are  con- 
cerned, and  it  is  unnecessary  to  dwell  upon  any  de- 
scription of  the  phenomena  of  the  disease. 

Doctrines  respecting  the  etiology  of  this  malady  are 
extremely  unsatisfactory,  while  it  is  by  all  conceded 
that  epilepsy  may  be  the  sequence  of  certain  imme- 
diate causes,  such,  for  instance,  as  blows,  the  irritation 
of  dentition,  mental  emotions,  and  prolonged  and  ex- 
cessive fatigue  or  anxiety. 

It  is  also  very  generally  supposed  that  these  excit- 
ing causes  would  be  ineffective  in  producing  a  long 
series  of  epileptic  seizures  were  not  some  predisposing 
cause  present. 

Of  the  nature  of  such  predisposing  cause  or  causes, 
only  a  vague  kind  of  knowledge  has  been  possessed. 

Heredity  has  been  regarded  as  the  great  predispos- 
ing cause,  but  in  what  manner  this  hereditary  tend- 
ency is  transmitted  there  has  been  no  satisfactory  ex- 
planation. To  assert  that  this  disease  is  hereditary 
implies  little  if  any  practical  knowledge  of  what  can 


EPILEPSY.  103 

be  done  for  its  relief  unless  we  are  prepared  to  deter- 
mine something  of  the  nature  of  the  inheritance.  It 
may  not  be  out  of  place  to  repeat,  what  has  already- 
been  stated,  that  it  is  scarcely  reasonable  to  suppose 
that  one  disease  is  the  direct  sequence  of  another ;  or 
that  epilepsy  is  directly  inherited  from  chorea  or 
phthisis.  The  inheritance,  then,  is  a  tendency  or  'pre- 
disposition^ and  not  the  disease  itself. 

Is  the  tendency,  then,  a  part  of  the  physical  con- 
formation inherited  by  the  offspring,  or  is  it  some 
spiritual  essence  which  passes  from  parent  to  child? 

This  latter  alternative  need  not  at  the  present  day 
engage  our  attention.  Diseases  are  neither  entities, 
which  find  a  lodgment  in  the  systems  of  certain  per- 
sons and  there  work  out  their  malign  missions,  nor  are 
they  spiritual  manifestations.*  They  are  physical  ir- 
regularities, depending  upon  physical  causes  and  obey- 
ing physical  laws. 

It  is  not  to  be  presumed  that  all  the  mystery  of  in- 
heritance in  disease  will  ever  be  revealed,  nor  is  it  at 
all  probable  that  all  the  obscurities  which  surround  the 
subject  of  epilepsy  will  ever  be  lifted  away,  yet  it  is 
possible  that  sufficient  light  may  penetrate  this  dark- 
ness to  enable  us  to  hope  for  better  results  from  treat- 
ment than  have  heretofore  rewarded  the  efforts  of  the 
physician. 

If  the  views  of  hereditary  tendency  in  nervous  dis- 

*  This  view  does  not  imply  that  toxic  agents  are  not  destructive, 
nor  that  microscopic  organisms  may  not  so  multiply  in  certain  parts,  or 
in  the  whole  body,  as  to  generate  disease,  nor  does  it  ignore  many  other 
forms  of  injurious  or  destructive  agencies. 
8 


104  FUNCTIONAL  NERVOUS  AFFECTIONS. 

eases  whicli  have  already  been  suggested  in  discussing 
tlie  subject  of  neuralgia,  and  which  will  be  somewhat 
further  discussed  in  a  section  to  be  devoted  to  the  sub- 
ject of  heredity,  are  correct,  an  important  element  in 
heredity  is  to  be  found  in  the  construction  of  the  eyes 
and  of  their  surroundings. 

However  extravagant  the  view,  that  an  hereditary 
tendency  to  nervous  diseases  may  descend  with  this 
physical  feature,  may  appear  to  one  who  has  not  fully 
considered  it,  it  can  not  in  the  light  of  facts  be  dis- 
missed. 

There  may,  in  view  of  all  the  knowledge  which  can 
at  present  be  brought  to  bear  upon  the  subject,  be  dif- 
ferent estimates  of  the  frequency  and  of  the  impor- 
tance of  this  factor  in  the  cause  of  the  neuroj)athic 
tendency,  but  its  existence  as  a  factor  must  be  ad- 
mitted. 

Without  attempting  further  discussion  of  this  as  a 
supposed  cause,  or  of  other  known  causes,  the  practi- 
cal results  of  experience  in  this  form  of  disease  will  be 
given. 

Examinations  of  ocular  conditions  have  been  made 
in  one  hundred  and  forty  cases  of  epilepsy,  eighty-five 
of  which  were  in  i^rivate  practice.  The  general  result 
of  these  examinations  has  been  to  reveal  the  existence, 
in  these  cases,  of  refractive  anomalies  in  a  considerably 
greater  projDortion  than  has  been  found  by  Cohn  in  his 
examinations  of  the  eyes  of  school-children,  or  by 
other  observers  in  similar  investigations  prosecuted  in 
Germany,  Russia,  and  America. 

In  one  hundred  consecutive  cases  there  existed : 


EPILEPSY.  105 

Hypermetropia    (including    hypermetropic 

astigmatism)  in  59 

Myopia  (including  myopic  astigmatism)  in .  23 
Emmetropia,  or  refractive  errors  less  than 
ID 18 


100 

In  four  of  the  cases  in  which  notable  errors  of  re- 
fraction were  not  observed,  atrophy  of  one  of  the  eyes 
existed. 

In  the  greatest  number  of  cases  examined  in  private 
practice  very  marked  insufficiency  of  the  motor  mus- 
cles of  the  eyes  was  found,  and  it  may  be  here  ob- 
served that,  so  far  as  ocular  irritations  are  concerned 
in  the  origin  of  a  tendency  to  epilepsy,  muscular  irreg- 
ularities are  doubtless  much  more  efficient  than  refrac- 
tive anomalies. 

The  proportion  of  refractive  errors  stated  above, 
would  not  of  itself  prove  a  relation  between  the  state 
of  the  eyes  and  epileptic  condition,  although  the  pro- 
portion is  notably  in  excess  of  that  found  by  examina- 
tions of  those  in  health.  This  circumstance,  however, 
taken  with  that  of  a  state  of  insufficiency  of  the  ocular 
muscles  existing  very  generally,  renders  it  probable 
that  the  ocular  defects  may  be  in  relation  to  the  epi- 
leptic tendency. 

The  facts,  however,  which  have  already  been  pre- 
sented in  regard  to  other  nervous  affections  must  have 
a  certain  weight  in  this  connection,  and  must  add  to 
the  probability  of  the  relations  suggested. 

If  now  we  add  to  these  evidences,  which  are  in 


106  FUNCTIONAL  NERVOUS  AFFECTIONS. 

themselves  only  important  suggestions,  the  results  of 
treatment  based  upon  the  supposition  of  ei^ileptic  in- 
fluence arising  from  ocular  defects,  we  shall  find  it 
certain  that  these  relations  are  of  the  highest  import- 
ance. 

Of  the  eighty-nine  cases  examined  in  private  prac- 
tice, thirty-four  only  have  been  treated  and  observed 
for  any  length  of  time  beyond  one  or  two  visits.* 

Of  this  number  five  have  withdrawn  from  treatment 
before  obtaining  any  relief  from  important  ocular  de- 
fects, and  should  not  be  included  in  calculating  the 
results  of  treatment.  The  remaining  twenty-nine  cases 
have  been  treated  only  by  the  removal  of  ocular  de- 
fects. Of  these  twenty-nine  cases,  fourteen  may  be  con- 
sidered well ;  two,  who  are  still  under  observation,  are 
believed  to  be  permanently  relieved  ;  three  others,  still 
under  treatment,  have  received  such  marked  relief  that 
it  is  believed  that  an  entire  discontinuance  of  the  mal- 
ady may  be  expected.  One,  who  had  manifested  some 
improvement,  died  of  accident  four  months  after  his 
first  visit.  Seven  others  have  received  temporary  re- 
lief, while  two  have  manifested  no  improvement. 

In  order  that  a  proper  estimate  may  be  made  of  the 
value  of  treatment  directed  to  the  eyes  in  these  cases, 
a  considerable  number  of  them  will,  at  the  risk  of  de- 
manding some  patience  on  the  part  of  the  reader,  be 
reported  at  such  length  as  to  enable  one  to  determine 
whether  the  results  have  been  incidental   and  facti- 

*  In  the  haste  of  preparing  tliis  memoir  as  originally  presented,  a 
few  cases  of  epilepsy  were  overlooked  ;  hence  these  numbers  do  not  ex- 
actly correspond  with  those  given  in  the  original  paper. 


EPILEPSY.  107 

tious,  or  legitimate  sequences  of  scientific  treatment 
directed  to  the  removal  of  the  cause  for  the  disease. 
It  is  proper  to  add  that  the  question  of  the  influ- 
ence of  drugs  in  the  treatment  is  eliminated  by  the  fact 
that  in  some  cases  none  had  been  taken  for  a  consider- 
able time  before  treatment  directed  to  the  ocular  con- 
ditions, and  in  cases  in  which  they  had  been  used  up 
to  the  time  that  the  patient  came  under  observation, 
they  have  in  every  instance  been  at  once  discontinued. 
Mr.  W.  H.  A.  came  by  the  advice  of  his  attend- 
ing physician,  Dr.  A.  T.  Woodward.     The  patient 
had,  during  nearly  four  years,  suffered  from  at- 
tacks of    epilepsy,    occurring    about  once  in  two 
months,  but  sometimes  more  frequently.     During 
some  months,  from  September,  1875,  to  June,  1876, 
he  used,  by  the  advice  of  his  physician,  atropine  in 
considerable  doses,  with  the  effect  of  lengthening 
the  intervals  between  the  attacks  slightly,  but  since 
discontinuing  the  medicine  they  have  returned  with 
more  than  usual  frequency. 

His  eyes  were  examined  August  24,  1876,  and  he 
was  found  to  have  hypermetropia  ^.  The  defect  was 
corrected  by  glasses,  and  the  attacks  ceased  until  the 
following  year,  when,  after  discontinuing  the  use  of 
the  glasses  a  month,  an  attack  occurred.  The  use 
of  glasses  was  at  once  resumed,  and  the  patient  has 
continued  free  from  the  malady  wp  to  the  present 
time. 

In  the  two  following  cases  the  irritation  unques- 
tionably originated  in  the  ciliary  tract,  although  not 
from  refractive  or  muscular  difficulties,  but  from  the 


108  FUNCTIONAL  NERVOUS  AFFECTIONS. 

fact  that  the  ciliary  nerves  were  involved  in  the  cica- 
tricial tissue : 

C.  D.,  five  years  of  age,  was  examined  in  March, 
1878.*  He  had  been  subject  to  very  frequent  epi- 
leptic attacks  during  more  than  a  year  past.  Con- 
vulsions occurred  generally  as  often  as  once  in  two 
or  three  d'djs.  The  child  was  also  suffering  from 
other  general  diseases,  and  was  feeble  and  irrita- 
ble. 

The  right  eye  was  staphylomatous,  protruding  so 
prominently  as  to  prevent  closure  of  the  lids.  It  was 
learned  that  in  infancy  he  suffered  from  ophthalmia 
neonatorum,  and  that  the  staphylomatous  condition 
had  been  the  result  of  this  disease. 

The  ruined  eye  was  at  once  removed,  and  with  its 
removal  both  the  epileptic  seizures  and  the  other  affec- 
tions ceased — no  attack  of  ei)ilepsy  occurring  after  the 
day  of  the  operation. 

J.  W.,  aged  fifteen,  had  been  subject  to  epilepsy 
since  he  was  eleven  years  of  age.  When  he  was 
ten  years  old  he  had  had  erysipelas  of  the  face  and 
had  lost  the  right  eye,  which  had  become  atroi)hied, 
the  cornea  and  ciliary  region  being  involved  in  a 
dense  cicatrix.  A  year  after  the  attack  he  became 
epileptic,  and  from  that  time  he  had  been  subject 
to  very  frequent  fits,  often  to  three  or  four  a  day. 
The  eyeball  was  removed  in  May,  1882,  and  the  re- 
moval was  succeeded  by  immediate  relief  from  epi- 
lepsy.    He  was  seen  several  months  later,  when  the 

*  This  case  was  reported  in  " The  Alienist  and  Neurologist"  for 
January,  1880. 


EPILEPSY.  109 

trouble  had  not  returned,  but  has  since  then  not  been 
seen. 

H.  J.  E.  applied,  bringing  a  letter  from  his  at- 
tending physician,  Dr.  W.,  May  15,  1880.  The  pa- 
tient has  been  subject  to  epilepsy  for  two  years. 
At  first,  attacks  occurred  once  in  two  weeks,  but 
under  the  influence  of  large  doses  of  bromides 
the  frequency  was  reduced  to  about  once  in 
three  weeks,  an  improvement  which  continued 
from  March,  1879,  to  June  following.  Then, 
while  still  using  the  same  medicine,  the  attacks 
increased  in  frequency,  averaging  once  in  four 
days. 

Seizures  have,  of  late,  been  followed  by  marked 
psychical  disturbances.  There  is  much  mental 
confusion  ;  he  does  not  recognize  friends,  and  some- 
times wanders  far  from  the  scene  of  attack  before 
consciousness  returns. 

The  patient  is  a  miner,  and  is  much  of  the  time 
forced  to  look  sharply  upward.  Examination  of  the 
eyes  shows-  hypermetropia  -^  ;  adducting  power  re- 
duced to  10°,  abducting  to  2°.  Glasses  were  directed, 
and  the  unyielding  muscles  trained  to  greater  flexibil- 
ity. In  two  weeks  the  adducting  power  was  50°  and 
the  abducting  9°. 

The  epileptic  seizures  ceased  after  the  first  few  days, 
and  the  patient  was  permanently  relieved.  He  has 
been  seen  from  time  to  time,  his  condition  has  been, 
in  an  respects,  greatly  imi)roved,  and  he  has  been 
free  from  epilepsy. 

Mr.  F.  H.,  thirty-two  years  of  age,  was  sent  by 


110  FUNCTIONAL  NERVOUS  AFFECTIONS. 

his  physician,  Dr.  William  H.  Robb,  of  Amsterdam, 
New  York,  March  12,  1880. 

The  patient  was  a  man  of  large  frame  and  finely 
developed,  yet  from  his  early  youth  he  had  been 
subject  to  serious  nervous  affections.  As  a  child 
and  lad  he  had  suffered  from  intolerable  headaches, 
especially  during  school- days.  These  were  usually 
accompanied  by  nausea  and  often  by  vomiting.  In 
1872,  after  a  severe  illness,  he  became  subject  to 
epilepsy.  His  attacks  increased  from  year  to  year 
in  frequency  and  intensity.  During  the  past  year 
attacks  of  great  violence  and  of  long  duration  oc- 
curred every  month,  while  others  of  less  severity 
occurred  every  few  days.  He  continued  to  be  the 
subject  of  dull  headaches  and  of  pain  in  the  back, 
was  habitually  and  excessively  constipated,  and 
was  extremely  irritable.  His  memory  was  im- 
paired, and  he  was  constantly  subject  to  a  state  of 
mental  confusion. 

He  was  found  to  have  insufficiency  of  the  external 
recti  muscles,  and  on  the  day  of  his  first  visit  an 
operation  for  tenotomy  of  one  of  the  interni  was  made. 
The  relief  was  so  decided  that  he  visited  his  fam- 
ily physician  on  the  same  day  to  express  his  satisfac- 
tion. It  was,  as  he  declared,  as  though  a  load  had 
been  removed.  Within  the  next  three  months  three 
attacks  oi  petit  mat  were  experienced.  Great  improve- 
ment in  health  was  manifested  from  the  beginning. 
No  other  attacks  have  occurred  during  the  four  and 
one  quarter  years,  and  he  no  longer  suffers  from  men- 
tal confusion,  from  head  or  back  aches,  he  is  no  longer 


EPILEPSY.        •  111 

constipated,  and,  indeed,  declares  himself  in  every  re- 
spect well.* 

The  following  case  of  hystero-epilepsy  is  intro- 
duced here  as  one  of  much  interest  in  this  connec- 
tion, even  if  not  strictly  within  the  class  of  cases  under 
discussion : 

A  young  lady  was  seen  at  the  request  of  and  in 
company  with  her  physician.  Dr.  Thomas  Feather- 
stonhaugh,  in  1879. 

During  many  months  the  patient  had  been  in  a 
distressing  condition  of  hystero-epilepsy.  Epilepti- 
form attacks  occurred  several  times  a  day,  or,  in  some 
instances,  single  attacks  lasted  nearly  the  whole  day, 
and  during  the  intervals  she  was  in  a  state  of  great 
nervous  excitement.  Her  physician,  who  had  spent 
much  of  his  time,  both  day  and  night,  in  attendance 
upon  the  patient,  had  adopted  every  means  at  his 
disposal  for  her  relief,  even  to  the  administration  of 
chloroform  on  several  occasions,  the  administration 
having  been  on  some  of  these  occasions  continued 
for  hours  at  a  time. 

The  girl  was  remarkably  pale,  the  pulse  was 
rapid,  the  skin  was  cold  and  moist,  and  there  was  a 
bellows-murmur  with  the  first  sound  of  the  heart. 
The  ophthalmoscope  did  not  reveal  any  important 
refractive  error,  but  while  under  examination  the 
eyes  were  observed  at  times  to  turn  toward  the  nose 
with  strong  spasmodic  action.  The  pupils  were 
found  widely  dilated,  as  though  under  the  influence 
of  atropine.  These  conditions  suggested  insufiiency 
*  Freedom  from  epilepsy  continues  (1887). 


112  FUNCTIONAL  NERVOUS  AFFECTIONS. 

of  tlie  externi,  witli  enfeebled  action  of  the  ciliary 
muscles  from  habitual  suppression  of  accommoda- 
tion. 

The  attending  physician  was  advised  to  apply  a 
solution  of  pilocarpine  to  the  eyes,  with  a  view  of  stim- 
ulating the  ciliary  muscles.  This  was  done,  and  the 
nervous  phenomena  quickly  disappeared.  The  con- 
vulsions ceased,  and  did  not  reappear  after  the  first  day 
of  this  treatment.  The  young  lady  within  a  day  or 
two  visited  the  doctor  at  his  office,  quite  free  from  her 
malady,  and  there  has  been  no  return  of  it  to  the 
present  time. 

Miss  L.  was  sent  with  a  letter  from  her  attend- 
ing physician.   Dr.   F.   H.  Stevens,    now  of   Lake 
George,  New  York,  May  23,  1882.     She  had  had 
epileptic  attacks  during  more  than  two  years.     She 
had  been   subject  to    headache  and  neuralgia  as 
long  as  she  could  remember.     She  had  also  during 
a   number  of   years    suffered   much   pain   in    the 
epigastric  region.     During  the  first  year  of  epilep- 
sy, fits  occurred  usually  once  in  a  month,  in  con- 
nection with  the  menstrual  periods,  but  during  the 
last  year  she  had  had  attacks  every  two  or  three 
days.     The  convulsions  were  perfectly  character- 
istic of  the  more  severe  form  of  epilepsy. 
Examination  of  the  eyes  showed  hypermetropic  as- 
tigmatism 1  D.    Before  the  use  of  atropine,  there  was 
apparent  myopic  astigmatism  1  D,  showing  that  an 
extreme  tension  of  the  muscles  of  accommodation  ex- 
isted.   After  continuing  the  use  of  atropine  for  some 
days,  with  the  result  of  changing  the  refractive  state 


EPILEPSY.  113 

from  apparent  myopia  to  actual  hyperopia,  cylindrical 

glasses  were  prescribed  and  used. 

June  5tli,  she  was  seen ;  had  had  no  epileptic  seizure 

nor  headache. 

October  27th,  seen  again  ;  still  no  return  of  epilepsy 

or  of  headache. 

Ai^ril  24,  1883,  called  at  my  consulting-room ;  still 

no  return  of  the  disease. 

From  the  attending  physician  it  is  learned  that 

the  young  lady  has  continued  well  up  to  the  i)resent 

writing,  more   than  a  year  and  a  half  since  her  first 

visit. 

[Mr.  H.  T,,  aged  thirty-seven,  consulted,  June  3, 
1880,  by  advice  of  his  physician.  Dr.  Charles  G. 
Clark,  of  Troy,  New  York.  He  has  been  an  epi- 
leptic five  years ;  has  had  seizures  from  four  to 
six  times  a  day.  Is  in  other  respects  in  very  poor 
health,  looks  dull  and  lethargic.  He  has  used  bro- 
mides freely  up  to  the  present  time. 

He  was  found  to  have  hyperopia  of  -jV  for  one 
eye  and  of  ^  for  the  other,  with  insuflBciency 
of  the  externi.  July  10,  1880,  tenotomy  of  the 
intemus  of  one  eye  was  made,  followed  a  few 
weeks  later  by  similar  operation  on  the  other 
eye.  All  medicines  were  discontinued  from  the 
first. 

On  the  day  preceding  the  first  operation  he 
had  had  five  severe  epileptic  fits,  and  on  the  morn- 
ing of  the  operation  several  more.  From  the  date 
of  the  first  operation,  however,  the  epileptic  attacks 
ceased,  and  not  a  single  return  of  the  malady  has 


114  FUNCTIONAL  NERVOUS  AFFECTIONS. 

occurred  up  to  the  present  time.  *  His  health  im- 
proved in  all  respects.] 

[I.  B.,  aged  fifteen,  was  brought  for  examination 
by  the  advice  of  her  physician,  Dr.  A.  H.  Allen,  of 
New  London,  Connecticut,  April  17,  1884.  She  was 
in  early  childhood  an  intelligent  and  in  most  respects 
a  healthy  child,  subject  only  to  nervous  attacks. 
At  the  age  of  twelve  she  became  an  epileptic,  sub- 
ject to  severe  attacks  from  three  to  five  times  a  day. 
These  attacks  were  characterized  by  severe  convul- 
sions and  total  unconsciousness,  lasting  from  ten  to 
thirty  or  more  minutes.  In  addition  to  these  severe 
attacks,  the  milder  seizures  of  petit  mat  occurred 
many  times  a  day.  Evidences  of  the  deplorable 
effects  of  the  disease  upon  the  girl's  mind  were 
soon  manifest.  She  became  dull,  morose,  and  feeble- 
minded, losing  from  month  to  month  the  vivacity 
which  had  characterized  her  in  earlier  years. 

After  making  use  of  such  means  for  relief  as 
were  suggested  by  several  comi)etent  physicians 
with  little  or  no  favorable  result,  her  parents  were 
induced,  a  year  before  her  first  visit  to  me,  to  ad- 
minister in  large  doses  a  secret  preparation  which 
proved  to  be  mainly  a  saturated  solution  of  bro- 
mide of  ammonia. 

Dementia,  after  this  treatment,  became  the  most 
pronounced  feature  of  her  disease.  The  fits  were 
less  frequent,  and  indeed  were  at  one  time  absent 
during  several  weeks.  It  was  known,  however, 
that  the  failure  even  for  a  day  or  two .  to  administer 
*  This  relief  Las  continued  up  to  the  present  time  (1887). 


EPILEPSY.  115 

the  drug  would  be  followed  by  a  renewal  of  the 
attacks,  and  during  the  two  months  preceding  her 
visit  to  me,  notwithstanding  the  use  of  six  drachms 
of  the  solution  daily  (about  240  grains  bromide),  the 
fits  had  returned  in  nearly  the  former  frequency. 
The  face  was  devoid  of  any  expression  of  intelli- 
gence, and  saliva  flowed  from  the  angles  of  her 
mouth.  When  attempting  to  speak,  as  she  did  only 
in  monosyllables,  the  voice  was  smothered  in  the 
fluids  of  the  mouth.  Indeed,  the  patient  presented 
a  typical  picture  of  marked  dementia. 

Her  attendants  believed  that  she  did  not  see  well, 
and  as  nearly  as  could  be  ascertained  there  was 
slight  apparent  myoi)ia,  with  f^  vision.  The  eyes 
being  brought  under  the  influence  of  atropine,  the 
ox)hthalmoscope  revealed  hyi^eropia  1"50  D.  There 
was  an  appearance  of  decided  insufficiency  of  the 
externi,  but  there  was  too  little  intelligence  on  the 
part  of  the  patient  to  admit  of  any  exact  determi- 
nation by  the  equilibrium  tests. 

The  bromide  solution  was  discontinued  at  once, 
and  a  little  wine  was  administered  two  or  three 
times  daily,  and  convex  glasses  1  T>  were  used. 
Under  this  regime  some  improvement  in  the  mental 
and  physical  condition  could  be  observed  after  the 
first  week.  The  fits,  however,  became  more  fre- 
quent and  severe  in  proportion  to  her  recovery  from 
the  influence  of  the  drug.  Thus,  during  the  week 
ending  May  3d  there  occurred  flf  teen  fits,  in  each  of 
which  unconsciousness  continued  from  ten  to  thirty 
minutes.    During  the  week  ending  May  31st  there 


116  FUNCTIONAL  NERVOUS  AFFECTIONS. 

were  twenty-nine  very  severe  attacks,  and  attacks 
of  jpetit  mal  in  gi-eat  numbers. 

By  tlie  29 til  of  May,  after  almost  daily  trials,  it 
was  hoped  that  some  progress  had  been  made  in  the 
knowledge  of  the  relations  of  the  eyes,  and  it  was 
supposed  tliat  an  insufficiency  of  the  externi  of 
from  10°  to  20°  at  twenty  feet  existed  while  using 
the  convex  glasses. 

With  a  clear  understanding,  on  the  part  of  the 
father  of  the  girl,  of  the  difficulties  attending  the 
determination  of  precise  conditions  under  the  cir- 
cumstances, and  with  his  full  approval,  an  opera- 
tion for  insufficiency  of  the  externi  was  made  on  the 
right  eye,  June  4th,  and  two  days  later  a  similar 
operation  on  the  left,  after  which  the  appearance  of 
the  eyes  was  improved,  and  little  if  any  insuffi- 
ciency was  shown  by  the  tests,  such  as  could  be 
made. 

June  1st,  she  had  five  lits. 

June  2d,  she  had  seven  fits  ;  and, 

June  3d,  she  had  five. 

From  June  Uh  (the  day  of  the  operation)  to 
June  lltth  no  attacks  occurred.  From  June  14th  to 
June  21st  she  had  eight  attacks.  June  21st  to  June 
28th,  three  attacks,  all  of  which  were  unusually 
light.     No  -petit  mal  since  June  4th. 

July  7th,  she  returned  home,  her  last  attack 
having  occurred  June  25th.  The  change  in  her 
mental  condition  had  been  since  the  operations 
truly  marvelous,  and  her  physical  condition  had 
equally  imi^roved.    The  photograveurs,  Figs.  1  and 


Q_ 


EPILEPSY.  117 

2,  Plate  III,  exhibit  the  changes  of  physiognomy 
which  occurred  during  a  single  month.  Fig.  1  is 
from  a  photograph  taken  Just  preceding  the  first 
operation ;  Fig.  2  is  from  one  taken  a  month  later. 

From  time  to  time  the  patient  has  been  seen. 
She  continues  in  robust  health  and  her  intellect  has 
returned.  An  attempt  to  send  her  to  school,  some 
months  after  her  return  home,  was  followed  by  a 
very  slight  relapse,  but  her  friends  were  advised  to 
wait  a  year  before  allowing  her  much  close  use  of  her 
eyes.  A  year  after  this  her  condition  continued 
good  with  no  return  of  the  malady,  and  a  year  and 
a  half  after  the  operation,  her  physician  wrote  that 
she  continued  well.  (I  have  heard,  indirectly,  just 
as  this  manuscript  is  about  to  be  sent  to  press,  that 
the  girl  has  a  renewal  of  her  attacks.  If  so,  she 
has,  beyond  a  doubt,  some  remaining  muscular 
disability,  which  may  still  be  removed.)]  * 

J.  P.,  aged  fourteen,  April,  1883.  Was  fairly 
well,  with  the  exception  of  an  attack  of  pneumonia, 
until  a  year  ago.  Then  had  his  first  attack  of  epi- 
lepsy. During  the  year  has  had  twelve  severe  at- 
tacks at  intervals  of  about  a  month,  and  many  at- 
tacks of  petit  mal. 

Examination  of  the  eyes  showed  hypermetropia. 
Eight  2  D,  left  2*25  D.  Insufficiency  of  external 
recti  7°. 

Glasses  for  partial  correction  of  hypermetropia 
were  used,  and  on  the  23d  of  April  partial  tenotomy 
of  the  internal  rectus  of  the  right  eye  was  made, 
*  Case  introduced  in  present  edition. 


118  FUNCTIONAL  NERVOUS  AFFECTIONS. 

followed  by  a  similar  operation  upon  the  internal 
rectus  of  tlie  left  on  the  29th  of  April.  May  1st,  no 
insufficiency  of  the  recti  muscles  is  manifest. 

The  last  attack  of  epilepsy  occurred  April  20th, 
three  days  before  the  first  tenotomy.  He  has  been 
well,  even  in  respect  to  petit  mcd,  more  than  seven 
months."^ 

G.  S.  G.,  July,  1883.  During  the  past  year  has 
had  quite  a  number  of  epileptic  attacks,  does  not 
know  exactly  how  many.  Has  a  feeling  of  inde- 
finable nervousness,  and  his  mind  is  so  much  affect- 
ed that  he  has  been  forced  during  the  whole  year 
to  abandon  his  business,  that  of  an  apothecary. 
Has  suffered  much  inconvenience  during  the  past 
eight  years  from  constipation. 

He  has  astigmatism  corrected  by,  right  eye  1  D 
cylindrical,  axis  90°  ;  left  eye  0'75  D  cylindrical,  axis 
90°.  There  are  also  slight  insufficiency  of  the  exter- 
nal recti  muscles  and  deficient  adducting  energy. 

The  patient  was  advised  to  use  correcting  glass- 
es, and  his  eyes  were  exercised  by  means  of  prisms. 

No  further  attacks  have  occurred,  the  obstinate 
constipation  is  entirely  relieved,  and  the  patient 
writes,  under  date  of  November  21st,  that  he  is 
quite  well. 

[Miss  M.,  aged  twenty-nine.  Subject  to  epilepsy 
and  chorea  from  the  first  year  of  her  life.  Epilep- 
tic attacks  occur  from  three  to  five  times  daily. 
Occasionally  the  fits  are  of  great  violence,  but  they 

*  Nothing  has  been  known  concerning  this  patient  since  the  above 
record  was  written  in  1883. 


EPILEPSY.  119 

usually  last  only  a  few  minutes.  She  has  never, 
since  her  first  year,  taken  objects  in  her  left  hand, 
that  side  being  most  affected  by  chorea.  The  left 
elbow  is  drawn  forward  and  strongly  against  the 
chest,  the  hand  turned  palm  outward,  backv^ard, 
and  upward.  The  left  arm,  and  in  less  degree  the 
whole  body,  are  in  constant  and  violent  motion.  If 
an  attempt  is  made  to  bring  the  arm  into  its  normal 
position,  the  whole  body  becomes  convulsed,  the 
face  distorted,  and  both  arms  move  wildly.  The 
visual  anomalies  were  hyperopic  astigmatism,  right 
eye,  1*00  D;  hyperopia,  I'OO  D,  left;  insufficiency 
of  the  externi,  amounting  to  diplopia  of  5°  when 
red  glass  was  used,  and  hyperphoria,  2°.  The  hy- 
perphoria and  astigmatism  were  treated  with  cylin- 
dro-prismatic  glasses.  Tenotomy  of  one  internus 
was  done  under  great  difficulties,  owing  to  the 
patient's  mental  state,  November  22,  1884,  and  of 
the  other,  January  3,  1885.  Great  relief  followed 
the  first  operation,  and  the  fits  ceased  from  the 
1st  of  December.  In  a  month  she  was  able  to  use 
the  left  hand  for  the  first  time  in  twenty-eight 
years  to  a  considerable  extent,  and  delighted  in 
showing  how  she  could  brush  the  windows  of  the 
consulting-room  with  a  napkin.  Her  intellect  im- 
proved, and,  as  will  be  seen  by  the  portraits  (Figs. 
1  and  2,  Plate  IV  ;  No.  1  taken  November  17,  1884, 
No.  2,  February  2,  1885),  her  head  came  to  the  nor- 
mal position,  and  her  appearance  in  every  respect 
was  better.  Up  to  April  20th,  when  the  last  rec- 
ord was  made,  there  had  been  no  return  of  epilepsy. 

9 


120  FUNCTIONAL  NERVOUS  AFFECTIONS. 

I  have,  however,  learned  that  during  the  summer 
the  fits  returned  in  less  frequency  and  degree.  A 
recent  letter  from  her  sister  informs  me  that  it  is 
the  purpose  of  her  friends  to  pursue  the  treatment 
which  resulted  so  favorably  still  further  as  soon  as 
circumstances  allow.*] 

The  statement  of  the  cases  given  above  demon- 
strates beyond  a  doubt  that,  in  the  treatment  of  epi- 
lepsy, examination  of  the  conditions  of  the  eyes  is  of 
sui)reme  importance,  and  that  with  sufficient  attention 
to  this  factor  among  causative  influences  tending  to 
epilepsy,  marked  progress  may  be  exx:)ected  in  its  treat- 
ment. 

It  is  further  to  be  remembered  that  relief  obtained 
by  removal  of  causes  is  radical,  permitting  a  complete 
return  to  health ;  while  relief  following  the  employ- 
ment of  bromides  is  only  such  as  is  obtained  by  a  pro- 
longed dulling  of  the  nervous  susceptibilities,  and  can 
only  cure  by  this  blunting  process,  which,  even  when 
resulting  in  any  continued  arrest  of  attacks,  leaves  the 
patient  in  a  deplorable  mental  and  physical  condition. 

MENTAL  DISORDERS. 

A  process  of  irritation,  so  prolific  of  nervous  dis- 
turbances as  difficulties  in  performing  the  visual  func- 
tion has  been  shown  to  be,  must,  in  the  nature  of  the 
case,  react  upon  the  mental  as  well  as  upon  the  senso- 
rial operations  of  the  nervous  system. 

It  is  not  within  the  design  of  this  essay  to  discuss 
the  subject  of  mental  alienation  further  than,  in  pass- 

*  This  case  is  not  in  original  MS. 


MENTAL  DISORDERS.  121 

ing,  to  apply  the  principles  already  established  to  this 
department  of  investigation. 

Many  instances  of  acute  mania  as  well  as  of  more 
chronic  and  less  violent  forms  of  mental  disturbances 
have  been  known  to  recover  in  a  manner  truly  surj^ris- 
ing,  upon  relief  being  afforded  from  some  perplexity  in 
the  ocular  operations. 

Thus,  a  young  lady  who  had  been  a  victim  of  acute 
mania  three  months,  who  had  already  spent  two  terms 
of  eighteen  months  each  in  lunatic  asylums,  and  who 
was  known  to  have  inadequate  accommodative  jDower, 
returned  to  her  normal  mental  condition  at  once  upon 
stimulating  the  accommodative  muscles  by  eserine. 

A  lady  who  had  been  a  teacher  and  had  worked 
very  hard  became  the  subject  of  hallucinations.  She 
imagined  herself  a  wheelbarrow,  and  that  she  was  be- 
ing trundled  about.  She  became  at  once  incapacitated 
for  any  employment,  and  was,  after  some  time,  taken 
to  a  sanitarium,  where  she  continued  during  nearly  a 
year  and  a  half.  During  this  time  the  hallucination 
changed,  and  she  imagined  a  face  looking  over  her 
shoulder  and  into  her  own.  If  she  was  awake  in  the 
night  the  face  was  with  her,  and  if  she  walked  or 
rested  it  never  left  her.  She  was  tormented  with  in- 
cessant and  violent  headache ;  slejDt  very  poorly,  and 
was  too  weak  to  endure  any  but  the  most  trifling  ex- 
ercise. 

She  had  insufficiency  of  the  external  recti  muscles, 
which  was  relieved  by  operations  u]Don  the  internal 
recti. 

On  the  morning  following  the  first  operation  she 


122  FUNCTIONAL  NERVOUS  AFFECTIONS. 

awoke  without  tlie  presence  of  her  demon,  which  has 
never  returned ;  with  the  second  operation  her  head- 
ache disappeared,  and  she  was  within  a  few  weeks  in 
vigorous  health. 

During  more  than  a  year  she  has  provided  for  her- 
self by  her  own  labor  as  a  copyist,  and  has  continued 
in  excellent  health."* 

This  case  is  fairly  representative  of  several  others 
•which  need  not  be  related. 

[Plate  y  represents  a  most  remarkable  change  in 
the  condition  of  an  insane  young  man.  The  history  of 
the  case  is  as  follows : 

The  patient  was  brought  to  me  by  his  parents, 
who  brought  also  a  letter  from  Dr.  P.  M.  Wise, 
Superintendent  of  the  Willard  Asylum  for  the  In- 
sane. According  to  the  history  given  by  the  parents 
at  their  first  visit,  October  12,  1886,  the  boy  had 
been  insane  a  year  and  ten  months  (according  to  the 
report  of  neighbors,  much  longer).  During  a  sea- 
son of  unusual  religious  interest  the  boy  became  un- 
questionably insane.  His  condition  was  gradually 
more  and  more  hopeless  until  his  friends  determined 
to  commit  him  to  the  asylum.  It  was  when  at  this 
institution  that  they  were  advised  by  Dr.  Wise  to 
take  the  patient  to  New  York.  When  first  seen  he 
was  stolid,  refusing  to  speak,  and  sadly  demented. 
He  wept  aloud,  and  wrung  his  hands  much  of  the 
time.      He  refused    food,   and,   indeed,  for  many 

*  The  author  is  permitted  to  refer,  in  connection  with  this  case,  to 
Dr.  R.  Speakman,  Wellesley,  Mass. ;  Dr.  A.  H.  Allen,  New  London, 
Conn. ;  and  Dr.  J.  Blake  Rohinson,  New  York. 


Ql 


MENTAL  DISORDERS.  123 

months  had  only  taken  it  as  it  had  been  placed  in 
Ms  month  by  others.  If  standing,  he  held  his  arms 
ont  in  an  imbecile  manner  with  the  fingers  spread 
apart.  The  saliva  flowed  in  streams  from  his  mouth 
to  the  floor.  He  was  thin  and  pale,  and  a  cold 
moisture  covered  the  skin.  In  this  pitiable  condi- 
tion it  was  difficult  to  obtain  exact  information  of 
the  ocular  conditions,  but  by  the  exercise  of  much 
patience  these  conditions  were  sufficiently  made  out 
to  enable  a  generally  correct  judgment  to  be  formed. 
Under  atropine  he  showed  hyperopia  1"00  D,  with 
insufficiency  of  the  extern!  4°.  On  the  14th  of  Octo- 
ber the  first  photograph  (Fig.  1)  was  taken,  and  on 
the  same  day  a  tenotomy  of  one  of  the  internal  recti 
was  done,  and  two  days  later  a  similar  operation 
was  made  on  the  opposite  internus.  From  that  day 
an  improvement  could  be  seen  in  the  lad's  mental 
state.  Within  a  week  he  was  so  much  improved  as 
to  amaze  those  who  had  seen  him  in  his  first  condi- 
tion. He  soon  began  to  take  food  of  his  own  ac- 
cord, and  in  two  weeks  he  was  in  a  fair  way  to  com- 
plete recovery.  On  N'ovember  2d  the  second  pho- 
tograph (Fig.  2)  was  taken,  eighteen  days  after  the 
first;  and  three  weeks  from  the  day  of  his  first 
visit  he  returned  to  his  home,  no  longer  insane. 
His  friends  were  advised  to  bring  him  again  after  a 
few  weeks,  which  they  wisely  did.  Slight  hyper- 
phoria was  then  found,  and  a  tenotomy  of  one 
of  the  superior  recti  was  done.  When  he  re- 
turned home  the  second  time  he  was,  so  far  as 
could  be  detected,  perfectly  well. 


124  FUNCTIONAL  NERVOUS  AFFECTIONS. 

The  photograplis  show  more  than  I  am  able  to  tell, 
but  even  they  do  not  convey  a  perfect  idea  of  the 
wonderful  revolution  which  had  taken  place  in  the 
mental  and  physical  condition  of  the  boy  in  eighteen 
days].* 

[Plate  YI  is  introduced  here  as  representing  one  of 
the  cases  treated  by  attention  to  ocular  conditions  at 
the  Willard  Asylum  for  the  Insane  during  the  summer 
of  1886.  Space  does  not  permit  of  a  history  of  any  of 
these  cases,  but  the  photographs  fairly  rei)resent  the 
average  change  of  physiognomy  in  these  people  who 
had,  during  many  years,  been  confined  in  an  asy- 
lum].* 

It  follows,  then,  that  in  mental  troubles,  also,  the 
condition  of  the  eyes  should  be  carefully  inspected, 
and  sudden  and  gratifying  relief  will  often  reward  at- 
tentions intelligently  directed  to  any  embarrassment 
which  may  hinder  them  in  the  performance  of  their 
offices. 

HEREDITY. 

Enough  has  been  shown  in  the  discussion  of  neu- 
ralgia to  render  it  evident  that  to  a  certain  extent  the 
construction  of  the  eyes  constitutes  an  imi)ortant  ele- 
ment in  hereditary  predisposition  to  neuroses. 

The  orbit  and  its  contents  are  facial  features,  which 
are,  in  their  general  form  and  relations  to  other  parts 
of  the  face,  characteristic  in  families.  The  resem- 
blances so  strikingly  exhibited  in  many  families  de- 
pend very  largely  upon  the  construction  of  this  portion 
of  the  face.  The  form  of  the  eyeball  and  the  length 
*  In  present  edition  only. 


> 


HEEEDITY.  125 

of  the  straight  muscles  are  materially  modified  by  the 
form  of  the  orbit.  A  broad,  flat  face  at  once  suggests 
to  the  oculist  a  hypermetropic  eye.  A  narrow  face, 
with  prominent  features,  is  more  likely  to  be  associ- 
ated with  a  lengthened  eyeball,  and,  if  the  bones  of 
the  face  are  quite  unlike  on  different  sides,  there  is  a 
presumption  of  astigmatism.  With  many  exceptions, 
these  general  rules  afford  a  tolerable  estimate  of  the 
conditions  of  the  eyes  ;  but  with  varying  dej)ths  of  the 
orbit  there  must  also  be  varying  lengths  of  muscles. 
In  many  families  a  want  of  equilibrium  of  muscles  is 
as  characteristic  a  feature  as  hypermetropia  or  astig- 
matism. 

Thus  in  the  family  of  case  No.  91  of  the  table, 
at  page  145,  the  patient  had  hypermetroj)ia,  and  had 
also  converging  strabismus.  She  had  one  brother  and 
three  sisters,  all  of  whom  were  cross-eyed.  Oculists 
often  meet  with  such  instances.  Hence,  the  muscular 
balance  of  the  eyes  as  well  as  their  refractive  condition 
enters  largely  into  the  composition  of  family  simili- 
tudes. 

If,  then,  the  eyes  in  certain  families  are,  as  facial 
features,  generally  too  short,  or  if  there  is  in  the  fam- 
ily a  tendency  to  squint,  even  if  the  tendency  is  not 
manifest  to  the  ordinary  observer,  there  is  imposed 
upon  that  family  an  inordinate  task,  either  in  accom- 
modating the  eyes  for  near  points  or  in  maintaining 
paralMism  of  the  visual  lines.  While  the  subjects  of 
such  defects  are  in  full  vigor,  or  while  the  parts  sub- 
jected to  the  unusual  demand  are  used  but  moderately, 
there  may  result  little  or  no  inconvenience. 


126  FUNCTIONAL  NERVOUS  AFFECTIONS. 

There  is  under  tliese  circumstances  sufficient  nerv- 
ous energy  to  supply  the  ordinary  draft  upon  the 
nervous  system  and  to  perform  this  extra  task ;  but  if 
other  excessive  calls  upon  the  nervous  energy  are  made 
and  the  surplus  vigor  is  expended,  the  difficult  task  of 
adjustment  or  of  accommodation  can  no  longer  be  per- 
formed without  manifestations  of  nervous  exhaustion. 
Hence,  so  long  as  no  assistance  is  rendered  to  these 
overtasked  muscles,  disease  or  nervous  i^rostration 
arising  from  their  disability  is  exceedingly  chronic, 
and  long  periods  of  rest  with  tonic  medicines  are 
required  in  order  that  a  sufficient  amount  of  reserve 
energy  may  be  acquired  to  perform  their  function  and 
also  the  requirements  of  active  life. 

The  same  nervous  irritation  does  not  always  react 
in  the  same  manner.  This  is  well  shown  in  Brown- 
Sequard's  experiments  in  tickling.  One  subject 
laughs,  another  cries,  a  third  has  contortions  of  the 
limbs,  and  the  fourth  tetanic  rigidity  of  the  muscles. 

In  case  of  irritation  from  difficult  accommodation 
from  refractive  anomalies  or  excitation  from  muscular 
insufficiencies,  family  characteristics,  such  as  hyper- 
metrojDia  or  insufficiency  of  the  externi,  for  instance, 
react  in  various  ways.  One  member  of  a  family  suf- 
fers from  migraine,  another  from  chorea,  and  a  third 
from  neurasthenia.  Again,  in  one  such  family  the 
neuropathic  tendency  consists  in  eyes  of  insufficient 
length,  while  in  another  family  the  tendency  may 
originate  in  a  want  of  equilibrium  of  muscles.  Thus 
the  various  forms  of  features,  when  deviating  from 
an  ideal  standard  of  anatomical  perfection,  may  give 


HEREDITY.  127 

rise  to  a  great  variety  of  anomalous  conditions  of  the 
eyes. 

It  is  very  generally  supposed  that  nervous  diseases 
prevail  to  a  greater  extent  in  our  own  times  than  for- 
merly. Should  this  prove  to  be  true,  which  is  quite 
likely,  it  is  interesting  to  consider,  in  connection  with 
this  supposed  increase  of  nervous  troubles,  the  fact 
that  at  the  present  time  the  eyes  are  j)re-eminently 
the  working  organs  of  the  body. 

When  the  amount  of  voluntary  effort  of  the  mus- 
cles of  accommodation  and  adjustment  of  the  eyes  de- 
manded by  the  exigencies  of  modem  civilization  from 
all  but  the  most  unskilled  class  of  laborers  is  consid- 
ered, it  must  be  seen  that  in  this  may  be  found  an 
explanation  of  any  increased  tendency  to  nervous  dis- 
eases. 

In  several  hundred  instances  the  history  of  diseases 
to  which  members  of  families  have  been  subjected  has 
been  ascertained  with  as  much  accuracy  as  possible. 
In  a  certain  proportion  the  history  has  been  obtained 
through  several  generations,  but,  as  it  is  in  most  cases 
impossible  to  obtain  any  history  beyond  immediate 
relatives,  efforts  were  principally  directed  to  obtain  a 
record  of  the  present  condition  of  parents,  brothers,  and 
sisters,  if  living,  and  of  the  cause  of  death  if  not  living. 

It  is  unnecessary  to  occupy  the  space  which  would 
be  required  to  exhibit  all  this  research,  and  a  table  is 
appended  to  this  essay  in  which  is  shown  the  results 
of  the  inquiry  in  one  hundred  cases  which  are  con- 
secutive with  certain  exceptions  here  explained. 

The  cases  chosen  are  all  cases  in  which  a  specified 


128  FUNCTIONAL  NERVOUS  AFFECTIONS. 

form  of  nervous  disease  existed  and  from  whicli  the 
I)atient  was  seeking  relief.  All  cases  of  simple  myopia 
or  cases  in  which  the  refractive  error  is  less  than  1  D, 
and  all  cases  of  simple  muscular  insufficiency  have 
been  rejected  from  the  list. 

Myoi^ia  is  a  variable  condition,  and  may  arise  from 
other  anomalous  forms  of  refraction.  Slight  refractive 
errors  may  or  may  not  be  the  expression  of  a  family 
characteristic  ;  and  muscular  insufficiencies  may  often 
result  from  refractive  errors.  Hence  all  these  cases,  in 
which  the  hereditary  influence  is  questionable,  are  left 
out. 

The  list,  then,  contains  consecutive  cases  of  nervous 
diseases  in  which  the  family  record  has  been  ascer- 
tained, and  in  which  refractive  errors  of  1  D  or  more, 
excluding  cases  of  simjole  myopia,  have  been  found. 

The  exclusion  of  muscular  insufficiencies  appears 
necessary,  and  yet  unfortunate ;  for,  while  these  con- 
ditions are  often  acquired  they  are  also  not  unfre- 
quently  hereditary,  as  has  been  shown. 

The  list  of  cases  consists  of  adults,  the  ages  rang- 
ing from  seventeen  to  sixty-four  years,  and  the  family 
record  contains  none  but  immediate  relatives — ^parents, 
brothers,  and  sisters. 

In  order  to  avoid  complications  which  might  arise 
from  including  the  diseases  incident  to  childhood,  and 
especially  as  there  is  often  a  want  of  knowledge  on 
the  part  of  those  of  whom  inquiry  is  made  as  to  the 
nature  of  disease  from  which  infant  brothers  or  sisters 
may  have  died,  all  children  under  the  age  of  twelve 
years  have  been  excluded  from  the  family  record. 


HEREDITY.  129 

We  have  thus  a  fair  representation  of  the  classes  of 
disease  to  which  families,  in  which  refractive  errors 
prevail,  are  subject. 

It  will  be  seen  that  chronic  nervous  diseases  prevail 
in  nearly  all  these  families,  and  it  should  be  remarked, 
in  passing,  that  in  family  records  in  which  neuralgia, 
headaches,  and  other  nervous  troubles  are  said  to  ex- 
ist, it  is  in  every  instance  to  be  understood  that  the 
disease  is  chronic,  one  to  which  the  person  is  habitual- 
ly subject ;  and  occasional  or  temporary  ailments  are 
in  no  case  included. 

Tliere  appear  in  this  table  fevers  and  other  acute 
diseases,  but  by  far  the  greatest  proportion  of  deaths 
has  occurred  either  from  very  chronic  complaints  or 
from  sudden  strokes  like  apoplexy  or  diseases  of  the 
heart.  If  it  is  remembered  that  cerebral  apoplexy  is 
often  the  result  of  an  atheromatous  condition  of  the 
arteries,  and  that  death  from  heart-disease,  although 
occurring  suddenly,  is  often  the  result  of  old  lesions, 
the  list  of  mortality  from  continued  causes  is  in- 
creased. 

The  cause  of  death  most  frequently  noticed  is  con- 
sumption, there  being,  among  two  hundred  and  seven 
deaths  in  these  families,  eighty-nine  from  this  cause. 

Consumption  is,  in  the  death  register  of  every  city, 
an  important  item. 

Among  the  deaths  of  persons  more  than  ten  years 
of  age  in  the  city  in  which  these  records  were  made,  in 
years  in  which  no  epidemic  prevailed,  less  than  twenty- 
five  per  cent  were  attributed  to  consumption.  In 
these  families  in  which  considerable  refractive  errors 


130  FUNCTIONAL  NERVOUS  AFFECTIONS. 

prevail  the  iDroportioii  is  mucli  greater,  being  no  less 
than  forty-three  per  cent. 

In  the  same  city  the  average  proportion  of  deaths 
from  Bright' s  disease  is  about  four  per  cent,  while  in 
this  list  about  seven  per  cent  have  died  of  that  dis- 
ease. 

Paralysis  and  apoplexy  constitute  five  per  cent  of 
the  death-rate  of  the  city,  while  in  the  table  the  pro- 
portion from  these  diseases  is  nine  per  cent. 

A  careful  study  of  this  record  of  disease  in  families 
with  high  degree  of  refractive  errors  must  impress 
every  thoughtful  student  with  the  following  important 
truths : 

1.  In  such  families  there  is  an  extraordinary  preva- 
lence of  nervous  disorders,  including  migraine,  neu- 
ralgia, insanity,  and  organic  lesions,  such  as  apoi)lexy 
and  paralysis. 

2.  That  consumption  and  Bright' s  disease  are  rife 
in  these  families. 

3.  That  the  higher  the  grade  of  refractive  anomalies, 
the  greater  is  the  proportion  of  these  last-named  dis- 
eases. 

It  can  not  fail  to  occur  to  one  who  compares  this 
table  with  the  facts  given  in  this  essay  that  families  in 
which  such  features  are  transmitted  are  subjected  to 
unusual  nerA'ous  tension  in  respect  to  a  most  important 
function,  and  that  this  waste  of  nervous  energy  in  per- 
forming an  ordinary  task  renders  the  members  of  such 
families  easily  subject  to  chronic  irritations  of  impor- 
tant organs  not  necessarily  in  the  immediate  vicinity 
of  the  seat  of  the  loss  of  power.     Hence,  again,  such 


HEEEDITY.  131 

complaints  as  pulmonary  consumption  are  but  little 
amenable  to  medical  treatment  for  the  reason  tliat  the 
primary  cause  continues. 

If  the  patient  with  phthisis  is  found  also  to  be 
the  subject  of  a  marked  refractive  anomaly  or  of  pro- 
nounced insufficiency  of  the  recti  muscles,  his  chances 
of  recovery  under  medical  treatment  must  be  greatly 
enhanced  by  relieving  him  of  these  unnecessary  bur- 
dens. 

Again,  in  families  predisjDosed  to  diseases  of  this 
class  it  must  be  evident  that  much  may  be  done  to 
avoid  them  by  relieving  the  unfavorable  conditions 
which  may  otherwise  lead  to  disease. 

THE  TREATMENT   OF   NERVOUS   DISEASES. 

From  what  has  gone  before,  it  follows  as  a  neces- 
sary conclusion  that  attention  to  ocular  conditions 
should  occupy  a  prominent  place  in  the  treatment  of 
nervous  disease. 

In  the  series  of  cases  upon  which  the  conclusions 
arrived  at  in  this  essay  have  been  based,  the  use  of 
drugs  has  been  almost  entirely  excluded.  In  rare 
cases  medicines  for  relief  of  temporary  symptoms  have 
been  administered,  but  it  can  not  be  said  that  the  re- 
sults, even  in  these  exceptional  cases,  have  been  to  any 
considerable  extent  attained  by  means  of  drugs. 

Nevertheless,  it  can  not  be  questioned  that  medi- 
cines which  act  as  tonics  or  in  various  ways  tend  to  the 
promotion  of  general  vigor  must  be  valuable.  In  the 
same  manner,  rest  and  change  of  air  and  scene  are 
known  to  exert  influences  favorable  to  the  temporary 


132  FUNCTIONAL  NEEVOUS  AFFECTIONS. 

relief  of  almost  every  form  of  neurosis ;  mental  emo- 
tions of  a  pleasing  character  and  the  influence  of  hope 
and  courage  are  all  powerful  auxiliaries  in  the  treat- 
ment of  this  class  of  complaints. 

All  these  facts  are  too  familiar  to  need  more  than  a 
passing  acknowledgment  of  their  value. 

If  these  means  have  been,  to  a  certain  extent,  ig- 
nored in  the  treatment  of  these  cases,  it  has  been  in 
the  conscientious  hope  that  by  confining  the  efforts 
strictly  to  what,  in  such  cases,  has  been  supposed  to 
be  the  primary  cause,  less  of  doubt  in  regard  to  the  re- 
sults of  treatment,  and  as  to  the  nature  of  the  difficul- 
ties which  it  was  hoped  to  remove,  must  exist. 

In  this  connection  the  teachings  of  the  illustrious 
Graefe  in  regard  to  asthenopia  are  extremely  appro- 
priate. 

Speaking  of  spontaneous  cures,  and  of  cures  by  cer- 
tain measures  not  radical,  he  says:*  "In  these  cases 
of  temporary  asthenopia,  fresh  air,  cold  water,  tonic 
medicines,  and  electricity  are  indicated.  "What  disap- 
pears under  such  treatment  is  only  the  symptoms  of 
asthenopia,  while  the  disturbance  of  the  equilibrium  of 
the  antagonistic  muscles  remains  and  the  least  sinking 
of  energy  recalls  the  former  difficulties." 

In  like  manner  neuralgia,  chorea,  and  other  nerv- 
ous difficulties  may  disappear  under  similar  treat- 
ment, but  it  is  the  pain  or  irregular  nervous  action 
which  has  disappeared  while  the  essential  difficulty 
may  remain. 

Leaving,  then,  the  discussion  of  these  means,  so 
*  "  Archiv  fur  Ophthalmologie,"  Band  8,  II,  346. 


TREATMENT.  I33 

familiar  to  all,  some  points  in  regard  to  the  removal  of 
causes  may  be  briefly  stated.  Although  so  large  a  pro- 
portion of  cases  find  their  origin  in  ocular  conditions, 
the  search  for  irritating  causes  should  by  no  means  be 
confined  to  that  class  of  influences.  The  state  of  the 
ear,  carious  condition  of  the  teeth,  the  constriction  of 
a  passage,  even  of  one  so  small  as  the  nasal  duct,  all 
may  act  as  permanent  or  primary  causes  of  disease. 
One  instance  has  been  cited  above  where  the  removal 
of  a  mass  of  cerumen  from  the  ear  has  been  followed 
by  immediate  relief  from  a  long-continued  and  severe 
neuralgic  affection.  Several  instances  of  relief  from 
nervous  affections  by  the  dilatation  of  constricted  pas- 
sages might  be  given,  and  the  relief  sometimes  ob- 
tained from  the  removal  of  decayed  teeth  is  familiar. 

Respecting  the  corrections  of  ocular  defects,  so 
little  has  been  left  by  the  illustrious  masters  Bonders 
and  Graefe  and  by  other  learned  ophthalmologists  that 
little  need  be  said  here,  except  to  ask  some  considera- 
tion for  a  few  points  which  have  received  less  attention 
than  their  merits  would  justify. 

The  use  of  prisms  for  gymnastic  exercise  has  been 
frequently  mentioned  in  these  pages.  Too  many  happy 
results  have  followed  the  use  of  this  simple  method  for 
increasing  the  tone  of  the  ocular  muscles,  to  leave  a 
doubt  of  its  eminent  value. 

In  cases  of  slight  difference  in  the  refractive  con- 
dition of  the  eyes,  as,  for  instance,  a  very  low  degree 
of  astigmatism  of  one  eye  and  emmetropia  of  the 
other,  there  frequently  arises,  for  reasons  which  need 
not  be  discussed  here,  a  want  of  comj)lete  adducting  or 


134  FUNCTIONAL  NEEVOUS  AFFECTIONS. 

abducting  power,  or  of  botli,  whicli  may  not  depend 
upon  any  very  considerable  degree  of  insufficiency  of 
the  ocular  muscles,  such  as  might  be  demonstrated  by 
the  equilibrium  test  at  six  metres,  yet  this  deficient 
power  for  easy  co-operation  of  the  eyes  is  an  important 
factor  in  asthenopic  and  other  nervous  symptoms. 

By  causing  the  patient  to  look  at  an  object  placed 
at  a  distance  of  six  metres,  directing  him  to  avoid  di- 
plopia by  the  action  of  the  adducting  or  abducting  mus- 
cles, as  the  case  may  demand,  while  prisms  of  gradu- 
ally increasing  strength  are  placed  before  the  eyes, 
these  muscles  are  separated  in  their  action  from  the 
action  of  the  accommodation  and  the  increased  ability 
to  adduct  or  abduct,  soon  shows  the  increase  of  tone  of 
the  muscles. 

In  the  text-books  on  ophthalmology  the  subject  of 
insufficiency  of  the  internal  recti  muscles  is  discussed, 
and  some  of  its  results  were  shown,  with  directions  for 
treatment.  The  subject  of  insufficiency  of  the  exter- 
nal recti,  however,  has  been  almost  wholly  ignored. 

Graefe,  indeed,  refers  to  this  subject,*  and  says 
that  he  has  performed  tenotomy  of  the  internal 
recti  on  two  occasions.  He  seems,  however,  not  to 
have  met  with  signal  success,  for  he  declares  that  the 
method  remains  more  interesting  than  practical  in 
comparison  with  the  more  peaceful  choice  of  specta- 
cles. 

A  few  other  attempts  have  been  made  in  this  direc- 
tion, but  the  result  of  all  seems  to  have  been  the  drop- 
ping of  the  subject  by  universal  consent. 

*  "  Archiv  fur  Ophthalmologie,"  Band  8,  II,  321. 


TEEATMENT.  135 

That  insufficiency  of  the  external  recti  muscles  is  a 
condition  equally  or  more  perplexing  in  the  function 
of  adjustments  of  the  eyes  than  insufficiency  of  the  in- 
ternal recti,  the  author  of  these  pages  can  not  doubt. 
The  effects,  however,  are  less  immediate.  The  patient 
affected  with  insufficiency  of  the  internal  recti  rises, 
perhaps,  from  the  perusal  of  a  book  with  aching  eyes ; 
but  the  subject  of  insufficiency  of  the  externi  may  re- 
turn from  the  opera  or  other  assembly  where  the  eyes 
have  been  held  fixed  upon  distant  objects,  to  suffer 
from  migraine  on  the  following  day.  ISTeurasthenia, 
chronic  headaches,  hallucinations,  vertigo,  and  insom- 
nia are  among  the  frequent  results  of  insufficiency  of 
the  external  recti. 

Three  hundred  and  fifteen  operations  for  the  relief 
of  insufficiency  of  the  external  recti  have  been  made 
by  the  author  in  cases  where  no  converging  strabismus 
existed.  In  each  case  patients  were  able  to  maintain 
and  were  accustomed  to  maintain  binocular  vision, 
but  at  an  expense  of  greater  than  the  normal  effort. 

The  operation  is  performed  by  bringing  the  tendon 
forward  by  means  of  a  hook,  as  in  the  operation  for 
strabismus,  when  the  central  fibers  are  divided  at  the 
sclera,  allowing  the  borders  of  the  tendon  and  the 
attachments  of  the  capsule  to  remain  uncut. 

The  operation  demands  careful  judgment  and  much 
delicacy  of  manipulation  on  the  part  of  the  surgeon. 
The  custom  of  introducing  a  blade  of  the  scissors  be- 
neath the  tendon  and  cutting  down  upon  it,  as  in  op- 
erations for  strabismus,  can  not  be  safely  followed  in 
these  cases.    The  division  through  the  conjunctiva  is 

10 


136  FUNCTIONAL  NERVOUS  AFFECTIONS. 

made  exactly  over  the  insertion  of  the  tendon,  and 
about  one  fourth  of  an  inch  in  extent.  The  point  of  a 
fine  blunt-hook  is  then  introduced  very  exactly  at  the 
tendinous  insertion,  and  the  latter  is  put  upon  the 
stretch.  A  pair  of  blunt-pointed  scissors  then  cuts 
down  between  the  hook  and  the  sclera,  dividing  care- 
fully each  way  from  the  center  by  several  little  cuts. 
The  capsular  connection  at  the  borders  of  the  tendon 
must,  in  all  cases,  be  preserved.  The  insertion  of  the 
tendon  is  somewhat  fan-shaped.  By  dividing  all  but 
the  extreme  fibers  at  the  borders,  the  tendon  lengthens 
slightly,  while  the  division  of  the  external  fibers  leav- 
ing a  central  band,  as  has  been  proposed  by  some 
who  have  suggested  partial  tenotomy  of  the  externi  in 
cases  of  insufiiciency  of  the  intemi,  results  in  very 
little,  if  any,  extension  of  the  tendon. 

The  advantage  of  the  operation  proposed  and  prac- 
ticed by  myself  is,  that  by  means  of  the  extreme 
outer  fibers  of  the  tendon,  or  where  greater  relaxation 
is  required,  by  means  of  the  close  connection  of  the 
capsule  to  the  outer  fibers,  a  considerable  relaxation 
may  be  obtained,  while  the  muscle  is  not  allowed  to 
fall  back,  as  it  is  in  the  operation  for  strabismus.  The 
operation  can  be  performed  in  all  essential  i)articulars 
without  the  aid  of  the  hook,  a  fine  mouse-tooth  forceps 
being  made  to  seize  the  tendon  at  its  insertion,  while 
the  scissors  by  successive  cuts  made  perpendicular  to 
the  sclera  divide  it  exactly  at  the  insertion. 

Relaxation  of  the  desired  extent  has  by  this  means 
always  been  obtained,  but  the  relief  to  the  insufficiency 
is  not  always  permanent,  for  the  healing  process  is 


TREATMENT.  I37 

sometimes  attended  with  a  degree  of  contraction  nearly 
or  fully  equal  to  the  advantage  gained  by  the  opera- 
tion, in  which  case  a  renewal  of  the  operation  upon  the 
same  or  the  opposite  eye  may  be  made. 

The  results  have  been  extremely  satisfactory,  al- 
though, as  might  have  been  expected,  in  attempting  a 
process  in  surgery  which  was  practically  new  and  be- 
fore tried  only  with  the  most  doubtful,  if  any  success, 
some  difficulties  have  attended  the  accomplishment  of 
the  end,  more  especially  in  the  earlier  cases. 

Whatever  difficulties  may  have  been  encountered, 
however,  have  been  insignificant  when  compared  with 
the  notable  and  even  surprising  advantages  resulting 
in  the  great  majority  of  instances. 

It  is  not  too  much  to  say  that  the  attending  disad- 
vantages are  less  in  this  than  in  almost  any  operation 
in  surgery  from  which  results  in  any  degree  commen- 
surate can  be  expected. 

The  use  of  the  extract  of  calabar  bean  or  of  the 
sulphate  of  eserine  applied  to  the  eyes  in  cases  of  de- 
ficient accommodative  energy  is  often  of  great  tempo- 
rary benefit  in  a  variety  of  nervous  conditions.  In- 
stances have  been  shown  in  the  foregoing  pages  in 
which  the  nse  of  this  agent  has  been  followed  by  the 
happiest  results,  and  many  more  might  be  given. 

In  cases  in  which  the  tension  of  accommodation  is 
extreme,  the  use  of  atropia  applied  to  the  eyes  is  often 
followed  by  immediate  relief  to  nervous  symptoms  and 
by  removing  a  chronic  condition  of  tension  may,  in 
some  instances,  effect  a  ]permanent  relief. 

The  researches  of  a  class  of  scientific  observers,  of 


138  FUNCTIONAL  NERVOUS  AFFECTIONS. 

whom  Cohn  may  be  justly  regarded  as  the  leader,  have 
shown  how  prevalent  among  children  attending  schools 
are  found  anomalies  of  refraction  of  the  eyes. 

As  the  work  of  these  children  is  to  be  performed 
principally  with  these  organs,  is  it  not  simple  justice 
to  them  that  the  function  to  be  most  employed  should 
be  enabled  to  be  used  with  the  least  possible  diffi- 
culty 1 

Children  are  sent  to  school  with  the  most  complete 
ignorance  on  the  part  of  parents  and  teachers  of  de- 
fects which  may  demand,  on  the  part  of  the  little  ones, 
great  expenditure  of  nervous  force,  and  they  are  re- 
quired to  keep  apace  with  those  who  enter  upon  the 
same  work  with  no  such  incumbrance. 

If  they  fail  to  perform  the  task  of  accommodating 
and  of  adjusting  the  eyes,  and  at  the  same  time  of 
maintaining  their  positions  in  their  classes,  they  are 
condemned  as  idle  or  stupid. 

If,  on  the  other  hand,  by  virtue  of  great  persistence 
and  determination,  they  succeed  in  keeping  abreast  of 
their  more  fortunate  companions,  they  perform  their 
task  at  the  expense  of  vital  energies,  and  often  lay  the 
foundations  for  future  disease.  If  it  were  required 
that  the  eyes  of  children  should  be  examined  before 
entering  schools,  and  if  the  indications  shown  by  such 
examinations  should  be  observed,  an  infinite  amount 
of  suffering  might  doubtless  be  avoided.  And  should 
the  custom  of  giving  careful  and  intelligent  attention 
to  the  conditions  of  the  eyes  become  general,  there  can 
be  no  doubt  that  the  prevalence  of  disease  of  the  nerv- 
ous centers  would  undergo  a  marvelous  reduction. 


TABLE 

Containing  tJie  records  of  diseases  in  the  families  of  one 
hundred  2yatients  suffering  from  nervous  comjylaints,  and 
in  ichom  marked  errors  of  refraction  have  been  found. 
The  table  includes  successive  cases  beticeen  the  ages  of  four- 
teen and  sixty-four,  stating  the  age  of  the  patient,  the  com- 
plaint for  which  he  or  she  was  treated,  the  refractive  con- 
dition, the  result  of  treatment  so  far  as  it  is  known,  with 
the  physical  condition  of  the  living,  and  the  cause  of  death 
of  those  not  living,  xohen  known,  of  parents,  brothers,  and 
sisters. 


TSo. 

Age  of 
patient. 

Nature  of 
complaint. 

1 

46 

Head- 
aches. 

2 

38 

Neural- 
gia. 

3 

41 

Migraine. 

4 

5 

30 
55 

Head- 
aches. 
Neural- 
gia. 

6 

37 

Neural- 

1 

31 

gia. 
Insom- 
nia. 

Eefractive 
error. 


H.  2-75. 
As.  1-00. 

H.  1-25. 

Ah.  1.00. 

n.  2-00. 

Ah.  1-00. 
Ah.  1-25. 


Kesult  of 
treatment. 


Cured. 
Cured. 

Cured. 

Cured. 
Cured. 


Not 
known. 
Cured. 


Family  history. 


Father  died  of  acute  disease ;  moth- 
er well ;  one  brother  has  neuras- 
thenia. 

Father  died  of  cholera;  mother 
died  of  cholera ;  one  brother  died 
of  fever ;  one  sister  died  of  con- 
sumption ;  two  sisters  well ;  one 
brother  well. 

Father  died  of  acute  disease ;  moth- 
er has  paralysis ;  two  brothers 
died  of  Bright's  disease ;  two 
brothers  well;  two  sisters  have 
nervous  diseases. 

Father  well ;  mother  well ;  two  sis- 
ters have  chronic  neuralgia. 

Father  died  of  consumption ;  moth- 
er died  of  paralysis ;  no  brothers 
or  sisters. 

Father  died  of  paralysis;  mother 
well ;  four  brothers  well. 

Father  died  insane ;  mother  has 
had  hemiplegia;  three  brothers 
well ;  one  sister  well. 


140 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


No. 

Age  of 

Nature  of 

Eefractive 

Eesult  of 

patient. 

complaint. 

error. 

treatment. 

Family  history. 

8 

41 

Neuras- 

H. 5-00. 

Not 

Father  died   of   apoplexy;  mother 

thenia. 

known. 

well ;  one  brother  well ;  one 
brother  and  three  sisters  died  of 
consumption;  one  sister  died, 
cause  unknown. 

9 

30 

Head- 
aches. 

H.  2-7.5. 

Cured 

Father  died  of  Bright's  disease ; 
mother  well ;  one  brother  has  pa- 
ralysis ;  one  brother  well ;  two 
sisters  nervous  invalids ;  one  sis- 
ter well. 

10 

42 

Neural- 

n. 1-23. 

Not 

Father  died,  cause  unknown ;  moth- 

gia. 

As.  -50. 

known. 

er  has  headaches ;  one  brother 
died  of  disease  of  brain ;  one 
brother  died  of  heart-disease ; 
one  brother  died  of  consumption  ; 
one  brother  well. 

11 

45 

Epilepsy. 

H.  1-50. 

Not 
known. 

Father  died  of  pleuritis;  mother 
died  of  cancer;  two  brothers 
died  of  consumption  ;  one  sister 
well. 

12 

40 

Neural- 
gia, pa- 
ralysis. 

H.  2-00. 

Cured. 

Father  died  of  pneumonia  ;  mother 
died  of  consumption;  one  sister 
died  of  consumption. 

13 

48 

Neural- 
gia. 

n.  1-75. 

Cured. 

Father  died  of  fever ;  mother  died 
in  child-birth  ;  one  brother  is  an 
epileptic ;  one  brother  well ;  one 
sister  has  rheumatism  ;  one  sister 
well. 

14 

26 

Epilepsy. 

H.  300. 

Not 

Father    has     rheumatism ;    mother 

As.  2-00. 

known. 

died  of  Brij^ht's  disease;  one 
brother  died  from  accident ;  one 
brother  has  consumption;  two 
brothers  well ;  one  sister  well. 

15 

51 

Epilepsy. 

n.  1-25. 

Not 
known. 

Father  well;  mother  died  of  con- 
sumption; one  brother  well;  one 
sister  has  Bright's  disease;  one 
sister  well. 

16 

41 

Head- 
aches. 

n.  200. 

Cured. 

Father  died  of  consumption  ;  moth- 
er has  rheumatism ;  two  brothers 
died  of  consumption. 

11 

52 

Head- 

n. 2  25. 

Not 

Father  died  of  fever  ;  mother  died 

aches. 

cured. 

of  consumption ;  one  brother  died 
of  consumption ;  one  brother  well ; 
one  sister  died  of  consumption ; 
one  sister  has  consumption. 

18 

24 

Neural- 
gia. 

H.  2-75. 

Cured. 

Father  died  of  cerebral  disease ; 
mother  well ;  three  sisters  well ; 
three  brothers  well. 

19 

48 

Neural- 

n. 100. 

Not 

Father  died   of    cerebral   disease ; 

gia. 

treated. 

mother  died  of  paralysis ;  one  sis- 
ter died  of  apoplexy ;  one  sister 
died  of  consumption. 

TABLE. 


141 


Age  of 
patient. 

Nature  of 
complaint. 

43 

Neural- 

gia. 

43 

Vertigo. 

51 

Head- 

aches. 

51 

Vertigo. 

52 

Head- 

aches. 

58 

Neuras- 

thenia. 

40 

Neural- 

31 

gia. 
Neural- 

gia. 

34 

Neural- 

gia. 

40 

Neural- 

gia. 

64 

Head- 

aches. 

53 

Head- 

aches. 

30 

Neuras- 

thenia. 

Kefractive 
error. 


H.  1-25. 
H.  1-25. 

H.  2-75. 

H.  2-50. 

H.  1-75. 
H.  2-00. 

H.  1-25. 
As.  1-50. 

Ah.  2-00. 
Ah.  I -00. 

H.  1-25. 

As.  1-50. 
H.  1-25. 


Eesult  of 
treatment. 


Cured. 


Not 
treated. 


Cured. 


Cured. 


Cured. 


Not 
treated. 


Improved 
Cured. 

Cured. 
Cured. 

Cured. 

Cured. 
Cured. 


Family  history. 


Father  has  neuralgia ;  mother  well ; 
three  brothers  have  neuralgia ; 
one  sister  has  neuralgia. 

Father  well ;  mother  has  rheuma- 
tism ;  one  brother  well ;  one 
sister  has  vertigo ;  one  sister 
has  I'hcumatism ;  one  sister 
well. 

Father  died  of  pneumonia  ;  mother 
well ;  one  brother  has  headaches  ; 
one  brother  well ;  one  sister  has 
rheumatism ;  one  sister  has  some 
nervous  disease ;  one  sister  died 
of  consumption. 

Father  died  of  consumption  ;  moth- 
er died  of  — ;  one  brother  has 
neuralgia ;  one  sister  has  neural- 
gia. 

Father  died  of  consumption ;  moth- 
er died  of  consumption  ;  one  sis- 
ter has  asthma. 

Father  died  of  rheumatism ;  moth- 
er died  of  fever;  six  brothers 
well ;  one  sister  has  consump- 
tion. 

Father  died  of  epilepsy ;  mother 
has  migraine. 

Father  died  of  acute  disease ;  moth- 
er subject  to  neuralgia ;  one  sis- 
ter has  consumption;  one  sister 
has  neuralgia. 

Father  subject  to  migraine  ;  mother 
well ;  four  brothers  well ;  one 
sister  well. 

Father  died  of  apoplexy ;  mother  has 
neuralgia;  one  brother  died  of 
consumption ;  one  brother  has 
consumption ;  one  sister  a  nervous 
invalid. 

Father  died  of  paralysis  ;  mother  of 
pleuritis ;  one  brother  of  con- 
sumption ;  one  brother  of  some 
nervous  disease ;  one  sister  has 
neurasthenia;  one  sister  died  of 
rheumatism ;  one  sister  died  of 
paralysis. 

Father  not  well ;  mother  has  can- 
cer ;  one  brother  well ;  one  sister 
well. 

Father  died  of  accident;  mother 
died  of  paralysis ;  one  brother 
well ;  one  sister  well. 


142 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


No. 

Ape  of 
patient. 

Nature  of 
complaint. 

Kefractive 
error. 

Kesult  of 
treatment. 

Family  history. 

33 

38 

Neural- 
gia. 

H.  2-50. 

Cured. 

Father  died  of  heart-disease  ;  moth- 
er has  neuralgia  ;  one  sister  has 
rheumatism  ;  one  sister  has  some 
nervous  disease. 

34 

42 

Neural- 

Ah. 1-00. 

Not 

Father   well ;     mother    well ;     two 

gia. 

treated. 

brothers     have     migraine;     one 
♦brother  has  neuralgia  ;  one  broth- 
er died  of  chorea;  one  died  of 
dysentery. 

35 

30 

Head- 
aches. 

Ah.  1-50. 

Improved 

Father  died  of  consumption ;  mother 
well ;  three  sisters  not  well. 

36 

61 

Insom- 

H. 5-00. 

Not 

Father  died  of  abscess ;  mother  died 

nia. 

treated. 

of  consumption;  two  brothers 
died  of  consumption;  one  sister 
died  of  consumption. 

37 

28 

Head- 
aches. 

H.  1-50. 

Cured. 

Father  well ;  mother  died  of  con- 
sumption; one  brother  died  of 
consumption;  one  brother  well; 
two  sisters  well. 

38 

45 

Neural- 

Ah. 1-25. 

Not 

Father  died  of  consumption ;  mother 

gia. 

treated. 

died  of  cancer;  no  brothers  or 
sisters. 

89 

24 

Neural- 

H. 2-75. 

Not 

Father  has  nervous  disease ;  mother 

gia. 

treated. 

has  neuralgia;  one  brother  in- 
sane; one  brother  has  chronic 
neuralgia ;  one  brother  well. 

40 

51 

Head- 

H. 1-76. 

Not 

Father  died  of  fever  ;   mother  died 

aches. 

treated. 

of  consumption ;  three  sisters 
died  of  consumption  ;  one  brother 
well. 

41 

35 

Epilepsy. 

H.  2-50. 

Improved 

Father  well ;  mother  has  glaucoma. 

42 

40 

Neural- 

U. TOO. 

Not 

Father  died  of  consumption  ;  mother 

gia. 

treated. 

died  of  — ;  one  brother  died  of 
heart-disease ;  one  brother  died 
of  — ;  one  brother  well ;  two  sis- 
ters well. 

43 

28 

Head- 
aches. 

As.  7-00. 

Cured. 

Father  well;  mother  has  rheuma- 
tism ;  one  brother  has  consump- 
tion ;  five  sisters  well. 

44 

61 

Head- 
aches. 

H.  2-25. 

Cured. 

Father  died  of  fever ;  mother  died 
of  consumption ;  four  sisters  died 
of  consumption. 

45 

49 

Head- 

As. 4-00. 

Not 

Father  died  of  consumption  ;  moth- 

aches. 

treated. 

er  died  of  consumption ;  one  sis- 
ter well. 

46 

26 

Neural- 
gia. 

H.  3-50. 

Cured. 

Father  died  of  Brigrht's  disease; 
mother  has  neuralgia  ;  two  broth- 
ers well. 

47 

53 

Neural- 

Am. 1-50. 

Not 

Father  died  of  old  age ;  mother  died 

gia. 

treated. 

of  Bright's  disease ;  one  brother 
of  erysipelas ;  one  sister  insane ; 
one  sister  well. 

TABLE. 


143 


No. 

Afre  of 

Nature  of 

Eefractive 

Eesult  of 

patient. 

complaint. 

error. 

treatment. 

Family  history. 

48 

52 

Melan- 

H. 1-00. 

Not 

Father   died   of    accident;    mother 

cholia. 

treated. 

died  of  jaundice ;  one  brother 
died  of  fever ;  one  brother  well. 

49 

42 

Neuras- 
thenia. 

As.  1-00. 

Cured. 

Father  died  of  consumption ;  mother 
well;  one  brother  died  of  con- 
sumption  ;  one  brother  well ;  four 
sisters  died  of  consumption; 
three  sisters  well. 

60 

32 

Chorea. 

E.  1-00. 

Not 
cured. 

Father  has  chorea ;  mother  well ; 
one  sister  has  chorea ;  one  broth- 
er has  chorea. 

51 

42 

Spinal  ir- 
ritation. 

H.  2-75. 

Cured. 

Father  died  of  fever ;  mother  well ; 
no  brothers  or  sisters. 

52 

52 

Neural- 
gia. 

H.  1-50. 

Cured. 

Father  died  of  Bright's  disease ; 
mother  died  of  Bright's  disease ; 
three  brothers  well. 

53 

46 

Neural- 

n. 1-25. 

Not 

Father   died   of   apoplexy ;  mother 

gia. 

known. 

died  of  angina  pectoris;  one 
brother  died  of  consumption. 

54 

30 

Head- 

H. 2-00. 

Cured. 

Father  died  of  consumption ;  mother 

aches. 

As.  1-00. 

died  of  cholera ;  one  brother  died 
of  fever;  one  brother  well;  one 
sister  has  pulmonary  disease. 

55 

44 

Mijraine. 

Am.  2-00. 

Cured. 

Father  died  of  consumption ;  mother 
died  insane;  one  sister  has 
chronic  neurasthenia. 

56 

30 

Chorea. 

H.  1-25. 

Cured. 

Father  well ;  mother  well ;  one  broth- 
er has  asthma ;  one  brother  well. 

57 

44 

Migraine. 

H.  3-00. 

Cured. 

Father  died  of  consumption ;  mother 
died  of  consumption ;  one  brother 
died  of  consumption ;  one  sister 
died  of  consumption;  one  sister 
died  of  paralysis. 

58 

47 

Insom- 

H. 1-50. 

Not 

Father   died   of   paralysis;  mother 

nia. 

knovni. 

died  of  cancer;  one  sister  has 
neuralgia ;  one  sister  died  of  some 
nervous  disease. 

59 

40 

Neuras- 
thenia. 

Ah.  1-25. 

Cured. 

Father  died  of  cause  unknown; 
mother  died  of  consumption;  one 
brother  died  of  consumption ;  one 
sister  has  neurasthenia. 

60 

27 

Head- 
aches. 

H.  3.50. 

Cured. 

Father  died  of  apoplexy;  mother 
well ;  one  brother  well ;  one  sister 
well ;  one  sister  has  migraine. 

61 

37 

Insane. 

H.  1-00. 

Cured. 

Father  has  neuralgia ;  mother  died 
of  apoplexy  ;  two  brothers  well. 

62 

54 

Neural- 
gia. 

H.  2-50. 

Cured. 

Father  died  of  old  age ;  mother  died 
of  consumption ;  two  sisters  died 
of  consumption ;  one  sister  well ; 
two  brothers  well. 

63 

32 

Muscular 
spasm. 

H.  1-50. 

Cured. 

Father  well;  mother  has  consump- 
tion ;  one  brother  well. 

144 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


Ko. 

Age  of 
patient. 

Nature  of 
complaint. 

64 

28 

Head- 
aches. 

65 

19 

Head- 
aches. 

66 

37 

Head- 
aches. 

67 

52 

Head- 
aches. 

68 

43 

Head- 
aches. 

69 

52 

Head- 
aches. 

70 

52 

Migraine. 

11 

42 

Migraine. 

72 

18 

Chorea. 

73 

42 

Spinal  ir- 
ritation. 

74 

14 

Epilepsy. 

75 

61 

Vertigo. 

76 

52 

Head- 
aches. 

Kefractive 
error. 


H.  3-00. 
Ah.  1-00. 

H.  1-25. 
H.  2oO. 

H.  1-00. 

n.  2-25. 


H.  2-25. 
H.  1-25. 

H.  4-00. 

H.  1-25. 
H.  2-50. 

H.  2-25. 
H.  2-25, 
H.  1-75. 


Eesult  of 
treatment. 


Cured. 
Cured. 
Cured. 

Cured. 

Cured. 

Cured. 
Cured. 

Cured. 

Cured. 
Cured. 

Cured. 
Cured. 
Cured. 


Family  historj'. 


Father  died  of  consumption ;  mother 
well ;  one  brother  well ;  one  sister 
well. 

Father  well ;  mother  has  neuralgia ; 
one  brother  has  chorea;  one 
brother  well. 

Father  died  of  Bright's  disease; 
mother  well ;  one  brother  died  of 
pneumonia ;  one  brother  has  heart 
disease ;  three  sisters  are  invalids. 

Father  died  of  Bright's  disease ; 
mother  died  of  aneurism;  one 
brother  died  of  consumption ;  one 
brother  well. 

Father  died  of  paralysis;  mother 
died  of  epilepsy ;  one  brother  died 
of  heart-disease ;  one  brother  has 
locomotor  ataxy ;  one  brother  has 
chronic  headache ;  one  sister  died 
of  some  nervous  disease  ;  one  si.s- 
ter  well. 

Father  died  of  fever ;  mother  well ; 
two  sisters  died  of  fever ;  two  sis- 
ters well ;  two  brothers  well. 

Father  died  of  consumption  ;  mother 
died  of  acute  disease;  one  brother 
died  of  fever ;  one  brother  has 
nervous  disease  ;  one  sister  died 
of  consumption;  two  sisters  died  of 
cerebral  disease ;  one  si.stcr  well. 

Father  died  of  heart-disease  ;  moth- 
er died  of  paralysis ;  one  brother 
died  insane ;  one  brother  well ; 
one  sister  died  of  tetanus ;  one 
sister  died  of  consumption. 

Father  well ;  mother  died  of  Bright's 
disease ;  two  brothers  well ;  one 
sister  not  well. 

Father  died  of  disease  of  heart; 
mother  died  of  cerebro-spinal 
meningitis ;  one  sister  died  in- 
sane; one  sister  was  insane;  one 
sister  died  of  locomotor  ataxy. 

Father  died  of  Bright's  disease ; 
mother  well ;  one  brother  has 
headaches. 

Father  died  of  consumption ;  mother 
died  of  — ;  one  brother  has  neu- 
ralgia :  one  sister  has  neuralgia. 

Father  died  of  consumption ;  mother 
died  of  consumption;  one  sister 
has  asthma. 


TABLE. 


145 


No. 

Age  of 

Nature  of 

Eefractive 

Result  of 

patient. 

complaint. 

error. 

treatment. 

Family  history. 

11 

40 

Neuras- 

n. 1-75. 

Not 

Father  died  of  apoplexy;  mother 

thenia. 

treated. 

died  of  consumption  ;  one  brother 
died  of  fever ;  one  brother  well ; 
two  sisters  well. 

IS 

45 

Migraine. 

Am.  l-7o. 

Cured. 

Father  died  of  consumption ;  mother 
died  of  consumption ;  one  brother 
well ;  five  sisters  all  have  migraine. 

19 

51 

Neural- 
gia. 

H.  1-25. 

Cured. 

Father  died  of  heart-disease ;  moth- 
er died  of  heart-disease;  one 
brother  died  of  — ;  one  sister 
died  of  — . 

80 

44 

Neuras- 

H. 1-00. 

Cured. 

Father   died   of  apoplexy;   mother 

thenia. 

As.  0-50. 

died  of  consumption ;  two  brothers 
well ;  one  sister  well. 

81 

56 

Head- 
aches. 

H.  1-75. 

Cured. 

Father  died  of  pneumonia ;  mother 
died  of  cancer ;  two  brothers  well ; 
one  sister  well. 

82 

37 

Neural- 
gia. 

n.  1-00. 

Cured. 

Father  died  of  — ;  mother  has  neu- 
ralgia ;  one  sister  has  neuralgia. 

83 

24 

Head- 
aches. 

Am.  16. 

Cured. 

Father  has  migraine ;  mother  died 
of  acute  disease ;  one  sister  died 
of  fever ;  three  brothers  well. 

84 

31 

Neural- 

H. 0-50. 

Cured. 

Father   died    of    angina    pectoris; 

gia. 

As.  1-00. 

mother  well ;  one  brother  died  in- 
sane. 

85 

40 

Spinal  ir- 
ritation. 

Ah.  1-00. 

Cured. 

Father  died  of  spinal  disease ;  moth- 
er died  of  consumption ;  one  sis- 
ter well. 

86 

20 

Neural- 

M. 4-00. 

Cured. 

Father  died  of  pneumonia ;  mother 

gia. 

Am.  1-50. 

has  neuralgia ;  no  brothers  or  sis- 
ters. 

87 

19 

Neural- 

Ah. 1-75. 

Not 

Father  died  of  pneumonia  ;  mother 

gia. 

known. 

has  migraine ;  five  brothers  well ; 
one  sister  has  migraine ;  one  sis- 
ter well. 

88 

30 

Neural- 
gia. 

H.  1-00. 

Cured. 

Father  has  asthma ;  mother  died  of 
consumption ;  five  sisters  well. 

89 

21 

Head- 
aches. 

Am.  1-00. 

Cured. 

Father  well ;  mother  has  headaches ; 
one  brother  well. 

90 

17 

Head- 

M. 5-00. 

Not 

Father  died  of  consumption ;  mother 

aches. 

Am.  1-00. 

known. 

died  of  consumption ;  two  brothers 
well ;  one  sister  has  migraine. 

91 

27 

Neural- 

H. 1-50. 

Not 

Father  died  of   consumption;   one 

gia. 

known. 

sister  has  migraine;  two  sisters 
well ;  one  brother  well ;  the  pa- 
tient, the  brother,  and  the  three 
sisters  all  have  strabismus. 

92 

43 

Neural- 

H. 1-25. 

Not 

Father  died  of  heart-disease ;  mother 

gia. 

known. 

has  rheumatism ;  two  brothers 
died  of  consumption ;  four  sisters 
died  of  consumption ;  one  brother 
well ;  two  sisters  well. 

146 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


No. 

Age  of 
patient. 

Nature  of 
complaint. 

Refractive 
enor. 

Result  of 
treatment. 

Family  history. 

93 

27 

Neural- 

M. 4-50. 

Cured, 

Father  has  rheumatism ;  mother  has 

gia. 

As.  1-25. 

migramc. 

94 

37 

Head- 

H.  1-75. 

Not 

Father  well ;  mother  has  consump- 

aches. 

known. 

tion  ;  one  sister  well. 

95 

40 

Neuras- 
thenia. 

As.  2-00. 

Father  well ;  mother  died  of  apo- 
plexy ;  one  brother  died  of  con- 
sumption ;  two  brothers  well ;  two 
sisters  well ;  one  sister  an  invalid. 

96 

21 

Head- 
aches. 

As.  1-00. 

Cured. 

Father  died  of  Bright's  disease; 
mother  well ;  one  sister  has  neu- 
rasthenia ;  one  sister  well. 

97 

48 

Neural- 
gia. 

n.  3-00. 

Cured. 

Father  died  of  abscess  of  the  liver ; 
mother  died  of  consumption ;  four 
sisters  well. 

98 

21 

Head- 
aches. 

As.  6-00. 

Cured. 

Father  has  phthisis ;  mother  an  in- 
valid; one  brother  died  of  con- 
sumption ;  one  sister  died  of  con- 
sumption ;  one  brother  well. 

99 

41 

Neural- 

H. 4-50. 

Not 

Father   died   of  apoplexv;  mother 

gia. 

known. 

well;  one  brother  died  of  acute 
disease ;  one  brother  died  of  con- 
sumption; three  sisters  died  of 
consumption;  one  sister  an  in- 
valid. 

100 

24 

Neural- 
gia. 

H.  1-75. 

Cured. 

Father  died  of  heart-disease ;  moth- 
er well ;  three  brothers  well ;  two 
sisters  well. 

Summary  of  the  above  Table. 

Average  age  (the  minimum  being  fourteen) 39 

Average  refractive  error 2'16 

Number  treated  in  which  results  were  known 72 

Important  relief  obtained  among  these  from  measures  directed  to  ocu- 
lar conditions  in i f>7 

Deaths  among  parents 129 

From  acute  diseases 26 

"     cerebrospinal  diseases,  epilepsy,  chorea,  insanity,  apoplexy, 

etc 28 

"    consumption 39 

"    Bright's  disease 14 

"     heart-disease  and  rheumatism 7 

"    miscellaneous  and  unknown  causes 15 

Parents  living 70 

Reported  to  be  in  good  health 35 

Suffering  from  nervous  disorders 21 

"  "     consumption 3 

"  "     rheumatism 6 

"  "    miscellaneous  disorders 5 


TABLE. 


147 


Deaths  among  brothers  and  sisters 

From  cerebro-spinal  diseases 14 

"     consumption 55 

"     Bright's  disease 2 

"     acute  diseases I3 

"    heart-disease  and  rheumatism 4 

"     unknown  causes 2 

Brothers  and  sisters  living 

Reported  well 148 

Suffering  from  nervous  diseases 51 

"           "     consumption 7 

"          "     Bright's  disease 1 

"          "    heart-disease  and  rheumatism 5 

"          "    invalidism 9 


90 


221 


SUPPLEMENT. 


If  the  doctrines  set  forth  in  this  work  are  worthy 
of  acceptance,  it  must  follow  that  a  knowledge  of  the 
refractive  and  muscular  anomalies  of  the  eyes  is  essen- 
tial to  the  most  successful  treatment  of  a  very  large 
proportion  of  nervous  complaints.  The  supplemental 
portion  of  this  work  is  prepared  with  the  view  of  af- 
fording the  practitioner  who  does  not  profess  to  be 
a  specialist  in  eye-affections,  a  general  understanding 
of  the  anomalies  to  be  sought  for  and  the  means  for 
their  correction.  No  effort  is  here  made  to  present  an 
exhaustive  or  a  critical  treatise.  One  who  would  pur- 
sue these  subjects  in  a  technical  manner  will  find 
abundant  material  for  study  in  a  part  of  this  field  in 
the  superb  works  of  Bonders  and  of  Landolt  ui)on 
"The  Refraction  and  Accommodation  of  the  Eye." 
Unfortunately,  there  are  no  text-books  in  which  that 
class  of  anomalies  of  the  ocular  muscle  known  as  "  in- 
sufficiencies," is  fully  discussed.  For  the  most  part, 
the  literature  of  this  subject  is  confined  to  a  single 
condition  of  "insufficiency,"  and  even  this  receives,  as 
a  rule,  but  a  passing  notice.  The  reader  will,  in  the 
pages  devoted  to  this  subject,   find  it  treated  very 


SUPPLEMENT.  I49 

briefly,  but  it  is  hoped  that  this  little  treatise  will 
enable  any  intelligent  practitioner  to  form  correct  con- 
clusions resiDecting  the  condition  of  the  eyes  of  his 
patients  in  this  respect. 

EEFEACTIOIS'   AND   ACCOMMODATION   OF   THE   EYE. 

The  eye  may  be  regarded  as  an  optical  instrument, 
similar,  in  some  respects,  to  a  camera- obscura,  such  as 
is  used  by  photograi^hers,  in  which  rays  of  light  are 
concentrated  by  means  of  convex  lenses  in  such  man- 
ner as  to  fall  upon  a  screen  at  the  rear  of  the  dark 
chamber.  If  the  screen  is  of  white  ground  glass,  an 
image  of  an  object  from  which  the  rays  emanate  may 
be  seen  upon  the  glass  by  an  observer  looking  from 
behind  the  screen. 

In  the  eye,  rays  of  light  pass  through  transj)ar- 
ent  media,  where  they  are  so  bent  or  refracted  as 
to  be  concentrated  upon  the  retina,  where  the  im- 
pression is  recognized  as  the  form  of  the  object  per- 
ceived. 

Rays  of  light  passing  from  space  into  the  eye  are 
refracted,  according  to  Bonders,  by  the  anterior  sur- 
face of  the  cornea,  the  anterior  surface  of  the  lens,  and 
the  anterior  surface  of  the  vitreous.  The  trans^Darent 
media  through  which  the  rays  must  pass  to  the  retina, 
and  in  which  the  refraction  is  accomplished,  form  the 
dioptric  system. 

The  ideally  normal  eye  is  so  constructed  that  rays 
from  an  infinite  distance,  that  is  to  say,  parallel  rays, 
in  traversing  the  dioptric  system,  are  brought  to  a 
focus  at  the  retina  without  an  effort  of  accommoda- 


150 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


tion.     This  normal  condition  of  tlie  eye  is  called  em- 
metropia. 

The  diagram  (Fig.  3)  shows  the  an^angement  of  the 
different  structures  of  the  eye  and  the  relations  of  the 

elem  en  ts  forming 
the  dioptric  sys- 
tem. The  tough 
membrane,  the 
sclera  (S.),  main- 
tains the  general 
form  of  the  globe, 
extending  back- 
ward to  inclose  the 
optic  nerve  (O.  N.), 
and  forward  as  far 
as  the  cornea  (C). 
Next  within  this 
sclerotic  membrane 
lies  the  vascular 
membrane,  the  choroid  (Ch.),  having  an  expanse  about 
equal  to  that  of  the  sclera.  The  cornea  is  transparent, 
permitting  rays  of  light  to  pass  into  the  eye,  where 
they  make  their  way  through  the  aqueous  humor  (A. 
H.)  and  pass  through  the  opening  in  the  iris  (I.),  which 
is  the  pupil.  The  rays  then  traverse  the  crystalline 
lens  (C.  L.)  and  the  vitreous  humor  (V.  H,),  at  length 
falling  upon  the  retina  (R.),  the  delicate  nervous  mem- 
brane which  extends  from  the  optic  nerve  and  lies  be- 
tween the  choroid  and  the  vitreous  humor.  If  the 
rays  are  brought  to  a  focus  on  the  retina,  this  focus 
lies  at  a  point  somewhat  external  to  the  point  of  en- 


FiG.  3. — Diagrammatic  section  of  the  eye.  «, 
sclera  ;  c,  cornea ;  i,  iris  ;  ch.,  choroid ;  r,  re- 
tina ;  ah,  aqueous  humor ;  cl,  crystalline  lens ; 
vh,  vitreous  humor ;  cap,  capsule ;  on,  optic 
nerve  ;  ml,  macula  lutea. 


SUPPLEMENT.  151 

trance  of  the  optic  nerve,  where  the  retina  becomes 
even  more  thin  and  delicate  than  in  its  general  ex- 
panse. This  point,  which  is  exactly  in  the  visual  axis, 
is  called  the  macula  lutea  (M.  L.).  The  point  at 
which  the  optic  nerve  enters  the  eyeball  is  called  the 
optic  disc.  The  crystalline  lens  is  held  in  position  by 
an  extremely  delicate  enveloping  membrane  called  the 
capsule  (Cap.),  which  is  connected  vdth  the  muscular 
ring,  the  ciliary  muscle  (C.  M.). 

If  an  object  which  is  clearly  defined  upon  the 
screen  of  a  camera  be  moved  nearer  to  the  instrument 
or  carried  farther  from  it,  the  image  upon  the  screen 
will  be  no  longer  well  defined,  but  indistinct.  In  this 
case  the  clear  definition  may  be  restored  by  changing 
the  relation  of  the  lenses  to  the  screen,  by  moving 
them  backward  or  forward,  or  the  lenses  may  be  re- 
placed by  others  having  greater  or  less  refracting 
power. 

If  the  eye  were  so  constructed  that  its  focal  adjust- 
ment was  always  the  same,  objects  only  within  a  cer- 
tain range  would  be  well  seen,  and  all  objects  re- 
moved beyond  or  brought  within  shorter  range  would 
be  indistinctly  perceived.  This  condition  is  provided 
against  by  the  faculty  possessed  by  the  eye  of  chang- 
ing, within  certain  limits,  its  refractive  state.  This  is 
called  the  faculty  of  accommodation,  and  it  must  be 
brought  into  action  whenever  the  eye  regards  objects 
nearer  than  the  most  distant  point  of  clear  vision  ;  and 
thus  during  waking  hours  it  is  almost  constantly  exer- 
cised. The  theory  of  the  mechanism  of  accommoda- 
tion of  the  eye  was  long  one  of  the  most  interesting  of 
11 


152  FUNCTIONAL  NERVOUS  AFFECTIONS. 

physiological  inquiries,  and  many  suppositions  and 
speculations  were  from  time  to  time  accepted.  The 
tirst  to  discover  and  to  demonstrate  the  actual  changes 
which  occur  in  the  exercise  of  this  important  function 
was  Dr.  Thomas  Young. 

From  the  era  of  Kepler  until  the  time  of  Dr. 
Young's  contributions  to  the  "  Philosophical  Transac- 
tions "  in  1801,  much  had  been  written  and  but  little 
had  been  known  of  the  nature  of  this  faculty  pos- 
sessed by  the  normal  eye  of  adapting  itself  to  bring  to 
a  focus  rays  of  light  emanating  from  points  at  differ- 
ent distances.  Young,  by  experiments,  and  by  what, 
had  they  been  properly  understood,  should  have  been 
regarded  as  conclusive  arguments,  showed  that  the 
change  of  focal  adjustment  of  the  eye  in  accommoda- 
tion depends  upon  alteration  in  the  degree  of  con- 
vexity of  the  crystalline  lens.  A  similar  hypothesis 
had  previously  been  held,  but  no  demonstrations  had 
been  adduced. 

Little  attention  was  paid  to  Young's  theory  un- 
til Helmholtz  and  Cramer,  working  independently, 
proved  by  mathematical  and  ocular  demonstrations 
the  truth  of  the  theory.  This  important  iDhysiological 
problem  having  been  solved,  it  remained  to  others,  and 
notably  to  the  illustrious  Professor  Donders,  to  de- 
velop the  theories  of  accommodation  and  refraction  in 
respect  to  individual  defects.  The  result  of  Professor 
Donders's  labors  in  this  direction  were  given  to  the 
world  in  his  great  work,  "  On  the  Anomalies  of  Accom- 
modation and  Refraction  of  the  Eye,"  published  in 
1864. 


SUPPLEMENT.  I53 

According  to  tlie  present  knowledge  of  the  function 
of  accommodation,  the  ciliary  muscle,  a  small  muscu- 
lar ring  situated  in  the  interior  of  the  eye  and  sur- 
rounding the  border  of  the  crystalline  lens,  acting 
ui^on  the  lens  in  such  a  manner  as  to  modify  its  curva- 
tures, and  hence  its  refracting  power,  is  the  seat  of  the 
faculty  of  accommodation. 

According  to  the  investigations  of  Cramer  and 
Helmholtz,  it  is  shown  that  in  the  act  of  accommo- 
dating the  eye  for  near  points  the  lens  becomes  con- 
vex, its  anterior  surface  advancing  toward  the  cornea, 
while  the  i^osterior  surface  remains  nearly  stationary, 
a  change  produced  by  the  contraction  of  the  ciliary 
muscle.  When  this  contraction  is  discontinued,  the 
lens  resumes  its  original  form,  and  the  eye  is  adjusted 
for  distance.  The  modification  of  the  convexity  of 
the  lens,  when  accommodated  for  distance  and  near 
points,  is  well  shown  in  the  accompanying  diagram : 


Fig.  4. 


In  Fig.  4  parallel  rays  are  shown  by  the  solid  lines 
which  enter  the  eye,  where  they  undergo  refraction 


154  FUNCTIONAL  NERVOUS  AFFECTIONS. 

and  meet  exactly  at  tlie  macula  lutea.  The  inter- 
rupted or  dotted  lines  represent  rays  coming  from  a 
near  point.  These  rays  diverge  as  they  ai)proach  the 
eye.  Hence,  if  they  are  to  meet  at  the  macula,  they 
must  be  more  strongly  refracted  than  the  parallel  rays 
represented  by  the  solid  lines.  To  accomplish  this  the 
ciliary  muscle  contracts,  thus  becoming  a  ring  of  less 
diameter.  (The  dotted  lines  at  the  ciliary  muscle  show 
the  change  in  its  form).  This  contraction  in  the  diam- 
eter of  the  ciliary  ring  relaxes  the  tension  ui)on  the 
capsule,  when,  by  its  innate  elasticity,  the  lens  as- 
sumes a  more  convex  form,  as  is  seen  in  its  dotted  out- 
line. This  stronger  convex  lens  now  refracts  more 
strongly  than  before,  and  thus  the  diverging  rays  are 
brought  to  a  focus  exactly  at  the  point  at  which  the 
distant  or  parallel  rays  were  when  the  eye  was  at  rest. 
As  soon  as  the  force  of  contracting  the  ciliary  ring 
is  removed,  its  diameter  is  increased,  the  tension  upon 
the  capsule  is  renewed,  and  the  lens  returns  to  its 
original  state. 

In  an  ideally  constituted  eye,  the  distant  point  of 
clear  vision  {punctum  remotum)  is  the  horizon  or  in- 
finite distance.  Parallel  rays  are  brought  to  a  focus 
without  effort  on  the  part  of  the  ciliary  muscle,  and 
pencils  of  light  from  the  retina  pass  out  of  the  eye 
in  parallel  rays.  Objects  situated  at  about  twenty 
feet  from  the  eye  send  to  it  rays  which  are  practically 
parallel,  and  hence  in  ophthalmology  objects  seen  at 
twenty  feet  are  regarded  as  at  infinite  distance. 

The  distance  between  the  remote  point  {punctum 
remotum)  and  the  nearest  point  {punctum  proxlmum) 


SUPPLEMENT.  155 

of  clear  vision,  representing  the  extent  of  accommo- 
dative power,  is  called  the  range  of  accommodation. 
Accommodation  is  a  positive  force  acting  only  in  pro- 
ducing clear  vision  as  objects  apiDroach  within  finite 
distance.  It  can  not  act  to  magnify  very  distant  ob- 
jects by  a  process  of  negative  accommodation. 

The  crystalline  lens,  like  every  other  tissue  of  the 
body,  becomes  less  elastic  with  each  year  of  life. 
Hence  the  power  of  accommodation  diminishes  and  the 
near  point  advances  toward  the  distant  on  account  of 
the  constantly  increasing  difficulty  of  changing  the 
curvatures  of  the  crystalline  lens  by  the  action  of  the 
ciliary  muscle. 

At  the  age  of  twenty  the  near  point  is  at  about  ten 
centimetres  (eight  and  a  half  inches)  from  the  eye, 
while  at  the  age  of  forty  it  has  reached  to  twice  that 
distance,  and  at  seventy-five  it  has  been  gradually 
transferred  to  the  remote  point.  In  other  words,  the 
faculty  of  accommodation  is  at  that  age  practically 
lost. 

It  is  evident  that  in  this  gradually  ]3rogressive  re- 
moval of  the  near  j)oint  there  must  come  a  time  when 
the  normal  eye  can  not  clearly  see  objects  within  the 
ordinary  distance  of  reading,  and  artificial  help  in  the 
form  of  glasses  becomes  necessary.  This,  to  the  best 
eyes,  occurs  between  the  ages  of  forty-five  and  fifty, 
and  the  condition  of  accommodation  demanding  such 
aid  is  called  presbyopia.  Presbyopia  is  not  necessarily 
a  failure  of  visual  power,  nor  is  it,  as  is  commonly  sup- 
posed, an  indication  of  perfect  eyes  that  one  is  able  to 
read  without  the  aid  of  glasses  after  the  age  of  fifty. 


156 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


People  who  read  without  glasses  after  that  age  are 
near-sighted,  or  have  some  other  defect  of  the  eye. 

As  the  practical  treatment  of  presbyopia  is  mate- 
rially modified  by  errors  in  the  refractive  condition  of 
the  eye,  its  further  consideration  will  be  resumed  after 
these  errors  have  been  discussed. 


EEFEACTION   OF   THE   EYE. 

All  eyes  are  not  constructed  on  the  plan  which  has 
been  shown  above.     Some  eyes  are  longer  and  some 
shorter  than  in  emmetropia,  and  some  have  irregular 
refracting    sur- 
faces.       These 
conditions,    va- 
rying from  em- 
metrojDia,     are, 
according        to 
D  onders,  known 
as  conditions  of 
ametropia. 


Fig.  5. — This  represents  the  form  of  the  emmetropic 
eye,  in  which  parallel  rays  are  brought  to  a  focus  at 
the  back  of  the  eye,  without  an  effort  at  accom- 
modatioQ. 


If  the  eye  is  short,  and  j^arallel  rays,  could  they 

pass  beyond 
the  back  of 
the  eye,  would 
come  to  a  fo- 
cus behind  the 
retina,  the  con- 
dition is  called 
hypermetro- 
pia  or  Tiype- 
ropia  (Fig.  6). 


.Fig.  6. — The  hyperopia  or  short  eye.  The  solid  lines 
represent  the  course  which  parallel  rays  would  take 
were  the  back  of  the  eye  transparent.  A  convex  lens, 
placed  in  front  of  such  an  eye,  gives  the  rays  the  di- 
rections shown  by  the  dotted  lines,  which  meet  at  the 
retina. 


SUPPLEMENT. 


157 


Fig.  7. — The  myopic  eve.  It  is  too  long.  Par- 
allel rays,  shown  by  the  solid  lines,  unite  before 
reaching  the  retina,  and  must  cross  and  fall 
upon  it  in  diffusion.  A  concave  lens  causes 
the  rays  to  enter  the  eye  in  a  diverging  man- 
ner, and  they  unite  farther  back,  as  shown  by 
the  dotted  lines. 


If,   on  the  contrary,  the  eye  is  long,  and  x)arallel 
rays  come  to  a  focus  in  front  of  the  retina,  the  con- 
dition is  kno\Yn  as 
myopia  (Fig.  7). 

An  astigmatic 
eye  is  one  in  which 
there  is  a  difference 
of  refraction  in  dif- 
ferent meridians. 
Thus,  in  one  meri- 
dian of  an  eye,  em- 
metropia  may  ex- 
ist ;  while  in  a  me- 
ridian at  right  angles  to  this,  myopia  or  hyperopia 
may  be  found. 

HYPEROPIA,    OR  FAR-SIGHT   (h.). 

Hyperopia  (Fig.  6)  is  one  of  the  most  common  con- 
ditions which  the  ophthalmic  surgeon  is  called  upon  to 
treat.  It  depends  generally  upon  the  form  of  the  eye, 
which  is  too  short,  and  dates  from  birth.  It  does  not 
increase  with  age,  except  in  a  slight  degree  after  the 
age  of  fifty,  but,  if  neglected,  may  pass  into  the  reverse 
condition,  myopia."^  As,  in  this  condition,  the  rays 
are  not  brought  to  a  focus  at  the  retina  but  behind  it, 
when  the  eye  is  at  rest,  even  distant  objects  are  not 
seen  clearly,  and  objects  at  near  points  are  still  less 
distinctly  seen.     But  if  the  faculty  of  accommodation 

*  Occasionally,  also,  hypermetropia  may  arise  from  too  feeble  re- 
fracting power,  on  account  of  flattening  of  the  cornea,  or  of  the  sur- 
faces of  the  lens,  or  on  account  of  absence  of  the  lens  (aphakia),  or  the 
refracting  power  of  the  aqueous  humor  or  lens  may  be  insufficient. 


158  FUNCTIONx^  NERVOUS  AFFECTIONS. 

is  called  into  exercise,  distant,  and,  with,  greater  effort, 
even  nearer  objects  are  seen  clearly.  The  ability  thus 
to  bring  the  focus  uiDon  the  retina  will,  however,  de- 
pend upon  the  degree  of  hypermetroi)ia  and  the  power 
of  the  ciliary  muscle  to  effect  the  accommodation.  As 
this  faculty  of  accommodation  is  exercised  without 
direct  consciousness  on  the  part  of  the  individual,  the 
fact  that  one  has  good  vision,  both  for  far  and  near 
points,  does  not  show  that  hyperopia  does  not  exist. 

It  will  be  seen  that  even  in  viewing  distant  objects 
the  accommodation  must  be  used,  and  a  greater  de- 
mand for  its  exercise  is  made  in  seeing  at  near  points. 
Hence  hyperopic  eyes  are  seldom  at  rest  during 
waking  hours,  and  a  constant  amount  of  contraction  of 
the  ciliary  muscle  is  demanded.  It  is  not  surprising, 
therefore,  that  hyi)eroi)ic  eyes,  especially  if  required 
to  perform  much  close  work,  as  in  reading  or  se^ving, 
suffer  from  a  condition  of  fatigue  known  as  accommo- 
dative asthenopia. 

The  symptoms  and  results  of  hyperopia  are  due 
largely  to  this  fatigue  of  accommodation,  but  the  per- 
plexity arising  from  the  absence  of  harmony  between 
the  functions  of  accommodation  and  of  convergence 
has  already  been  shown  in  the  first  part  of  this  work 
(page  19).  If  the  degree  of  hyperopia  is  slight  and  the 
power  of  accommodation  active,  little  inconvenience 
may  be  experienced ;  but  if  the  vigor  of  the  ciliary 
muscle  is  diminished,  the  eyes  become  painful,  a  dull, 
aching  sensation  is  felt  in  and  about  the  brows,  the 
patient  complains  that  letters  and  small  objects  be- 
come, after  a  short  use  of  the  eyes,  indistinct.     The 


SUPPLEMENT.  I59 

letters  of  a  page,  wliich  at  first  appear  clear,  after  a 
short  time  run  together,  and  it  becomes  necessary  to 
discontinue  the  work  while  the  accommodation  is  re- 
lieved. Pressing  the  eyes  with  the  hand,  when  this 
sense  of  fatigue  is  experienced,  is  a  common  and  char- 
acteristic means  of  relief.  If  the  act  of  accommodation 
is  persisted  in  after  these  warnings,  severe  pain  in  and 
about  the  brow  and  at  the  back  of  the  head,  general 
discomfort,  and  nausea,  may  follow.  As  a  result  of 
frequent  straining  of  the  muscles  of  accommodation, 
hyperopic  persons  often  have  redness  of  the  conjunc- 
tiva and  of  the  borders  of  the  lids.  The  more  general 
and  distant  reactions  have  been  shown  in  the  first  part 
of  this  work. 

In  the  higher  degrees  of  hyperopia  visual  acuity  is 
often  diminished,  so  that  even  with  correcting  glasses 
the  visual  power  is  considerably  less  than  the  stand- 
ard. 

Bonders,  to  whom  we  owe  the  knowledge  of  the 
relations  of  these  symptoms  of  fatigue  to  hyjperoiDia, 
divides  the  condition  into  latent  and  manifest  hyper- 
opia. 

In  latent  hyperopia  the  patient  unconsciously  uses 
his  accommodation,  and  thus  conceals  a  part  or  the 
whole  of  the  refractive  error.  This  is  especially  the 
case  with  young  persons,  in  whom  the  power  of  accom- 
modation is  active,  if  the  degree  of  hyperopia  is  only 
moderate ;  but  even  a  high  degree  of  hyperopia  may 
be  associated  with  a  vigor  of  accommodation  sufficient 
to  conceal  it.  As  age  advances,  however,  there  comes 
a  time  when  the  lens  being  less  elastic  than  in  earlier 


160  FUNCTIONAL  NERVOUS  AFFECTIONS. 

life,  tlie  accommodation  no  longer  suffices  to  render 
even  distant  objects  clear,  and  still  less  to  enable  the 
patient  to  read. 

The  hyperopia  is  now  manifest  in  part  at  least.  A 
suitable  glass  may  raise  distant  vision  to  the  normal 
standard  and  the  same  glass  may  enable  the  subject  to 
read. 

To  ascertain  the  absolute  amount  of  hyperopia,  it  is 
necessary,  especially  in  all  young  persons,  to  render 
the  latent  hyperopia  manifest,  which  can  be  accom- 
plished if  we  suspend  the  action  of  the  ciliary  muscle 
by  atropia  or  other  drugs  XDroducing  similar  effects. 

MYOPIA,    OR  NEAR-SIGHT   (m). 

Myoi:)ia  is  the  condition  opposite  to  hyperopia. 
The  axis  of  the  eye  being  usually  too  long  instead  of 
too  short,  as  in  hyjDeropia,  parallel  rays  are  brought 
to  a  focus  in  front  of  the  retina,  and,  before  reaching 
it,  cross  and  fall  upon  it  in  circles  of  diffusion  (Fig.  7). 

Hence,  rays  must  be  divergent  as  they  enter  the 
eye  in  order  to  meet  at  the  retina.  The  far  point  of 
vision,  then,  for  a  myopic  eye,  instead  of  being  at  in- 
finite distance,  is  brought  nearer,  and  a  myopic  eye  is 
consequently  a  near-sighted  eye.  The  distance  of  the 
remote  point  of  distant  vision  will  depend  upon  the 
amount  of  elongation  of  the  eye.  If  this  be  slight, 
there  will  be  a  correspondingly  slight  degree  of  myo- 
pia, or  near-sight.  If,  on  the  contrary,  the  elongation 
be  great,  there  will  exist  an  excessive  degree  of  near- 
sight. 

Myopia,  when  dependent  upon  anatomical  forma- 


te ^ 


SUPPLEMENT.  161 

tion,  is  scarcely  modified  for  tlie  better  by  treatment, 
but  unless  suitable  precautions  are  used  there  is  a 
strong  progressive  tendency.  Cases  of  slight  myopia, 
if  neglected,  are  liable  to  develop  rapidly  into  high 
degrees  of  near-sight.  It  is  important,  therefore, 
that  the  first  indication  of  near  -  sight  in  children 
should  receive  the  most  careful  attention.  The  popu- 
lar prejudice  which  existed  formerly  that  near-sight 
diminishes  with  age  is  erroneous,  and  should  never  be 
an  excuse  for  relaxing  the  most  vigorous  attention  to 
even  the  slightest  degree  of  myopia.  A  slight  change 
in  the  length  of  the  eyeball  after  the  age  of  fifty  is, 
in  this  connection,  a  matter  of  technical  rather  than  of 
practical  interest.  My  own  observations  have  con- 
vinced me  that  myox)ia  is  very  frequently,  if  not  in 
general,  one  of  the  results  of  anomalies  of  the  ocular 
muscles,  and  that  the  condition  most  conducive  to 
myopia  is  that  in  which  the  visual  line  of  one  eye 
tends  in  a  higher  direction  than  that  of  the  other. 

In  low  degrees  of  myopia  the  defect  may  escape 
observation,  as  objects  within  certain  distances  are 
clearly  seen,  and  the  fact  that  objects  beyond  this 
point  are  not  well  seen  is  not  regarded  by  the  patient 
as  in  any  way  peculiar.  Indeed,  people  with  moder- 
ately high  degrees  of  near- sight  often  become  aware 
of  their  defect  for  the  first  time  by  accidentally  put- 
ting on  concave  glasses,  which  reveal  to  them  objects 
at  a  distance  in  a  manner  to  them  surprisingly  clear. 
Usually,  however,  it  will  be  observed  that  the  myope 
holds  a  book  or  work  nearer  than  the  usual  distance, 
and  fails  to  recognize  distant  objects  as  well  as  other 


162  FUNCTIONAL  NERVOUS  AFFECTIONS. 

people.  In  low  or  moderate  degrees,  glasses  are  not 
required  for  reading  or  writing,  but  in  higher  degrees 
work  must  be  brought  very  near  to  the  eyes  in  order 
to  obtain  distinct  images,  and  in  these  cases  concave 
glasses  enable  the  myope  to  carry  the  book  or  other 
work  to  the  ordinary  distance.  In  near-sight,  if  of 
only  moderate  degree,  the  accommodation  is  com- 
monly used  in  reading  and  the  book  is  brought  near 
the  eyes ;  but,  as  age  advances,  the  eye  becomes  pres- 
byopic in  the  same  manner  as  in  emmetropia.  The 
near  point  recedes  toward  the  distant  i)oint,  and  thus, 
while  the  subject  of  myopia  can  see  at  no  greater 
distance  than  before,  there  is  a  necessity  for  removing 
objects  for  near  view  toward  the  distant  point.  The 
slight  change  in  the  refractive  condition  which  has 
been  alluded  to  above,  must  not  be  considered  here. 
The  range  of  vision,  then,  is  less  extensive,  but  the 
near-sight  remains.  It  was  upon  the  facts  that  the 
book  is  held  at  greater  distance,  or  that  the  glass  for 
near-sight  must  be  left  off  while  reading,  that  the 
popular  error  that  near-sight  decreases  with  age  was 
founded. 

Examining  the  history  of  near- sight  in  an  individ- 
ual, it  will,  in  the  majority  of  instances,  be  found  that 
until  the  age  of  from  ten  to  fifteen  years,  vision  for  dis- 
tance was  good,  but  that  near-sight,  then  appearing,  de- 
veloped rapidly.  In  a  certain  proportion  of  instances, 
however,  myopia  is  developed  at  a  very^arly  period 
of  life,  and  in  a  very  small  proportion  of  cases  it  may 
be  congenital. 

The  subjects  of  near-sight  often  suffer  from  redness 


SUPPLEMENT. 


163 


of  the  eyes  and  eyelids,  from  pain  in  the  brows  and 
general  headaches,  from  intolerance  of  light,  and  from 
the  presence  of  motes  in  the  field  of  vision. 

Near-sighted  eyes  are  commonly  diseased  eyes. 
The  rapid  elongation  of  the  eyeball  is  often  associated 
with  disease  of  the  choroid,  and  in  some  instances 
with  separation  of  the  retina  from  the  choroid.  A  con- 
dition called  posterior  staphyloma,  in  which  the  scler- 
otic is  distended  backward,  is  often  developed  in  my- 
opia. The  principal  changes,  as  described  by  Donders, 
are  "atrophy  of  the  choroidea  on  the  outside  of  the 
optic  nerve,  when  myopia  is  highly  developed,  com- 
bined with  change  of  form  of  the  nerve-surface,  a 
straightened  course  of  the  vessels  of  the  retina,  incom- 
plete diffuse  atrophy  of  the  choroidea  in  other  places, 
and  morbid  changes  in  the 
yellow  spot."  These  changes 
can  be  readily  recognized  by 
the  aid  of  the  ophthalmo- 
scope. Fig.  8  shows  the  irreg- 
ular, white  crescent  which 
marks  the  atrophy  of  the 
choroid. 

Besides  the  elongation  of 
the  axis  of  the  eye,  myopia 
may  be  the  manifestation  of 
the  increased  index  of  refrac- 
tion of  the  dioptric  media  or  of  excessive  curvature, 
as  in  conical  cornea. 

A  condition  of  involuntary  and  excessive  contrac- 
tion of  the  ciliary  muscles  {spasm  of  the  accommoda- 


164  FUNCTIONAL  NERVOUS  AFFECTIONS. 

tion)  sometimes  occurs  in  young  persons  simulating 
myopia,  and  generally,  after  a  time,  resulting  in  tlie 
anatomical  changes  of  myopia.  If  recogTiized  in  season 
the  contraction  of  the  ciliary  muscles  can  be  relaxed 
by  the  use  of  atropine  continued  for  several  days,  and 
thus  one  suifering  from  apparent  myopia  and  threat- 
ened with  organic  myopia  may  by  this  simple  measure 
be  saved  from  a  great  impending  misfortune.  Even 
this  relief  may,  however,  be  only  temporary,  for  if  the 
cause  of  strain  or  irritation  which  in  the  first  instance 
induced  the  spasm  of  the  ciliary  muscle  is  permitted 
to  remain,  the  same  spasm  may  return.  Hence,  as 
soon  as  the  spasm  is  relaxed,  every  effort  should  be 
made  to  find  and  to  remove  the  source  of  trouble, 
which  is  likely  to  be  found  in  some  unfavorable  rela- 
tions of  the  motor  muscles  of  the  eyes  or  in  some  per- 
plexing state  of  the  refraction. 

Myopia  prevails  mostly  among  the  educated  classes. 
The  tension  of  accommodation  demanded  in  looking 
during  many  hours  of  the  day  at  near  objects  acts  as 
an  immediate  cause.  This  cause  becomes  intensified 
in  case  the  light  is  insufficient  or  is  badly  arranged. 
Hence  the  evils  of  badly- illuminated  school-rooms 
have,  very  properly,  engaged  the  attention  of  those 
who  have  studied  the  causes  of  myopia.  Repeated 
examinations  in  schools  and  universities  on  a  large 
scale  have  shown  that  myopia  is  progressive  from  the 
lower  to  the  higher  classes,  a  greater  percentage  of 
myopia  existing  in  the  higher  classes  than  in  the 
lower.  This  increase  in  the  percentage  of  myopia  is 
not  to  be  wholly  accounted  for  by  such  causes  as  de- 


SUPPLEMENT.  165 

fective  light  or  illy-constructed  desks.  The  cause 
must  be  sought  for  in  conditions  more  radical  than 
these.  The  relations  of  the  ocular  muscles  constitute, 
in  my  opinion,  the  most  imi^ortant  predisposing  cause 
of  myopia,  and  in  this  direction  the  most  careful 
search  should  be  made  and  the  most  Judicious  precau- 
tion should  be  exercised.  This,  however,  should  not 
for  a  moment  encourage  any  relaxation  from  the  most 
minute  regard  for  the  hygiene  of  the  school-room  or 
of  offices  or  other  places  in  which  the  ejes  are  brought 
into  prolonged  use  at  close  range.  Defective  light, 
imiDure  air,  and  too  greatly-prolonged  exercise  of  the 
accommodation  of  the  eyes,  all  consj)ire  to  act  as  im- 
mediate causes  of  myopia. 

Myopic  children  naturally  find  less  pleasure  in  out- 
of-door  amusements  than  other  children,  and  are  in- 
clined to  employ  much  of  their  time  in  reading.  This 
inclination  should  be  checked,  and  the  amount  of  close 
work  performed  by  the  child  should  be  rather  less 
than  in  excess  of  the  amount  of  similar  work  allowed 
to  an  emmetropic  child. 

ASTIGMATISM. 

Parallel  rays  of  light  traversing  a  convex  si^herical 
lens  (not  regarding  spherical  aberration)  unite  beyond 
the  lens  in  a  luminous  point.  If  the  lens  be  bent  in 
such  manner  that  the  curve  in  one  direction  is  greater 
than  in  another,  say  at  right  angles  to  the  first,  the 
rays  are  not  united  in  a  point,  but  rays  passing 
through  the  part  of  the  lens  most  strongly  curved 
unite  first ;  those  traversing  the  part  or  meridian  of 


166  FUNCTIONAL  NERVOUS  AFFECTIONS. 

weaker  curvature  unite  at  a  greater  distance  behind 
the  lens.  If  the  rays  after  passing  through  such  a 
lens  were  received  upon  a  screen,  they  would  form  not 
a  point,  but  a  line. 

In  the  emmetropic  eye  the  dioptric  system  may 
be  regarded  j)ractically  as  a  spherical  lens,  but  in  as- 
tigmatism the  refraction  is  not  uniform  in  all  the  re- 
fracting meridians.  In  what  is  called  regular  astigma- 
tism, difference  of  refraction  exists  in  different  meridi- 
ans, the  greatest  and  least  refractive  power  being  in 
the  meridians  at  right  angles  to  each  other.  If  a  c. 
Fig.  9,  be  the  meridian  of  greatest 
refraction,  c  d  is  that  of  the  least. 

In  irregular  astigmatism  there  are 
different  degrees  of  refraction  in  dif- 
ferent parts  of  the  same  meridians. 
It  is  often  a  result  of  ulcer  of  the 
cornea  or  of  irregularities  in  the 
form  of  the  lens.  It  is  seldom  much  benefited  by 
glasses. 

Regular  astigmatism  exists  in  different  forms.  If 
the  meridian  of  greatest  refracting  power  is  emme- 
tropic, if  its  rays  unite  at  the  retina,  and  the  meridian 
of  least  refracting  power  be  hyperopic,  its  rays  unit- 
ing behind  the  retina,  it  is  called  hyperopic  astigma- 
tism. 

If  the  meridian  of  highest  refracting  power  is 
myopic,  its  rays  uniting  in  front  of  the  retina,  and  the 
meridian  of  least  refracting  power  be  emmetropic,  it 
is  myopic  astigmatism. 

If   both  the  meridians  of   greatest  and  least  re- 


SUPPLEMENT.  167 

fractive  power  are  liyperoj)ic,  one  more  than  the 
other,  it  is  compound  Jtyperopic  astigmatism. 

If  both  meridians  are  myopic,  one  more  than  the 
other,  it  is  compound  myopic  astigmatism. 

If  one  meridian  is  myopic  and  the  other  hyperopic, 
it  is  mixed  astigmatism. 

Astigmatism,  in  most  instances,  depends  upon  de 
fective  curvature  of  the  cornea,  which,  instead  ol 
being  curved  in  all  directions  alike,  is  more  strongly 
bent  in  some  directions  than  in  others. 

The  general  effects  of  astigmatism  are  similar  tc 
those  of  the  defects  of  refraction  already  described. 
In  low  degrees,  little  inconvenience  may  be  experi- 
enced in  the  act  of  seeing,  although  it  is  evident  that 
a  perfect  image  is  not  obtained.  In  the  higher  grades 
much  more  trouble  of  sight  results,  as  there  must,  oi' 
necessity,  be  much  confusion  in  the  focal  adjustment 
for  lines  constituting  an  image,  those  which  are  more 
or  less  nearly  at  right  angles  to  one  another  being  sub- 
ject to  different  focal  adjustments. 

In  reading,  the  astigmatic,  like  the  myopic  person, 
brings  the  book  near  the  eyes.  There  is  generally,  yd 
high  degrees,  defective  vision  even  when  correction  by 
glasses  is  made,  and  hypersemia  of  the  retina  is  not  an 
uncommon  complication. 

EXAMIJfATION   AliD   TREATMENT   OF  AMETEOPIA. — TEST- 
TYPES. 

Any  two  points  of  a  retinal  image,  in  order  to  be 
distinguished  from  each  other,  must  have  between! 
them    a    certain  distance.      This  distance   has    been 


168  FUNCTIONAL  NERVOUS  AFFECTIONS. 

shown  by  many  experiments  to  con^espond  to  a  visual 
angle  of  about  one  minute  in  tlie  emmetrox3ic  eye. 
Taking  this  princii)le  as  a  basis,  Snellen  constructed  his 
system  of  "test-types,"  which  has  been  universally 
adopted  for  the  demonstration  of  the  acuteness  of 
vision. 

The  objects  adopted  are  letters,  graduated  in  size, 
both  as  to  the  parts  and  the  whole,  to  correspond  to 
different  distances  from  one  foot  to  two  hundred  feet. 

In  order  to  test  the  acuteness  of  vision,  letters  are 
placed  at  a  point  sufficiently  distant  to  exclude  the  act 
of  accommodation.  The  point  most  generally  selected 
is  twenty  feet,  or  about  six  metres,  and  an  emmetropic 
eye,  with  normal  acuteness  of  vision,  should  read  the 
characters  of  No.  XX  (No.  6  of  the  new  system)  at 
twenty  feet.  If  only  No.  XL  can  be  read  at  twenty 
feet,  the  visual  acuteness  is  ff,  or  only  one  half  the 
normal.  If  only  the  type  which  should  be  read  at  one 
hundred  feet  is  read  at  twenty  feet,  the  visual  acute- 
ness is  ■^-^.  Thus  the  numerator  of  the  fraction  de- 
notes the  number  of  feet  at  which  the  eye  is  withdrawn 
from  the  type,  while  the  denominator  shows  the  line 
of  smallest  characters  which  can  be  read.  In  noting 
the  result,  we  write,  vision  |^,  if  normal,  or  vision  |^ 
or  1^,  as  the  case  may  be. 

In  general,  the  subject  of  the  examination  is  not 
allowed  to  approach  nearer  than  twenty  feet ;  but  if 
vision  is  very  defective,  he  is  allowed  to  approach  until 
the  largest  types  are  read.  Thus  vision  may  =  ■^^, 
etc.,  the  numerator  showing  the  distance  as  before. 

The  types  used  for  near  vision  are,  of  necessity, 


SUPPLEMENT.  169 

smaller.  The  smallest  slioiild  be  read  at  eighteen 
inches.  They  are  used  chiefly  for  testing  accommo- 
dation. 

The  following  is  copied  from  Snellen's  types: 

0.5  D 

The  Gallic  tribes  fell  off,  and  sued  for  peace.  ETen 
the  Batavians  became  weary  of  the  hopeless  content, 
■while  fortune,  after  much  capricious  hovering,  settled 
at  last  upon  the  Roman  side.  Had  Civilis  been  saccess- 
ful,  he  would  have  been  deified  ;  but  bie  misfortaneSf 
at  last,  made  him  odious  iu  spite  of  bi9  heroism. 

This  type  should  be  read  with  ease  at  the  distance 
of  one  half  metre,  but  in  testing  the  accommodation 
the  subject  is  required  also  to  read  it  at  twelve  inches. 

The  types  of  Iso.  XX  (6.  D,  new  system)  are  shown 
below. 


U 


m 


If  the  person  examined  reads  No.  XX  at  twenty 
feet  and  No.  0.5  at  about  one  and  a  half  foot  (one  half 
metre),  he  is  assumed  to  be  emmetropic.  He  is  not 
myopic,  as  he  Avould  not  be  able  to  read  the  characters 
at  the  greater  distance.  He  may,  however,  be  hyper- 
opic,  and  by  the  exercise  of  accommodation  distin- 
guish the  letters.  If  No.  XX  is  not  clearly  seen  with 
the  unaided  eye,  but  is  clearly  seen  with  a  convex 
spherical  glass,  the  focal  length  of  the  glass  indicates 
the  degree  of  manifest  hyperopia.  Thus,  if  the  focal 
length  of  the  glass  is  forty  inches,  the  manifest  hyper- 
opia is  ^,  or  in  the  more  modern  system,  1.  dioptry 
(H  manifest  =  1.  D). 

If,  on  the  contrary,  a  concave  spherical  glass  of 


170  FUNCTIONAL  NERVOUS  AFFECTIONS. 

forty  inches  negative  focus  (1.  D)  is  required  to  render 
No.  XX  distinct,  then  myoiDia  is  ^^V?  or  1.  D  (M  = 
l.D). 

In  determining  astigmatism,  radiating  lines,  the 
rays  equaling  in  thickness  the  limbs  of  the  letters  of 
'No.  XX,  are  used. 

In  testing  the  refraction  with  types  at  the  distance 
of  twenty  feet  the  accommodation  should  be  com- 
pletely relaxed.  This  is  most  effectually  done  by 
dropping  into  the  eye,  two  or  three  hours  before  mak- 
ing the  test,  a  small  quantity  of  a  solution  of  atropine 
of  the  strength  of  four  grains  to  the  ounce  of  water. 
This  is  rarely  necessary  after  the  age  of  forty,  and  not 
always  even  before  that. 

According  to  the  system  which  has  long  been  in 
use,  a  lens  is  numbered  according  to  its  focal  length, 
and  its  refractive  power  is  represented  by  a  fraction, 
of  which  the  numerator  is  1  and  the  denominator  the 
focal  length  in  inches.  Thus,  a  glass  of  twelve  inches 
focal  length  has  refraction  of  yV- 

A  new  system  has,  within  a  few  years,  been  intro- 
duced, in  which  the  unit  of  refraction  is  no  longer  | 
inch,  but  a  lens,  the  focal  length  of  which  is  1  metre. 
This  is  called  a  dioptry,  and  the  refracting  power  is  { 
metre.  A  lens  of  twice  the  refracting  power  would 
consequently  be  ^  =  2  dioptrics.  A  lens  of  one 
half  the  power  C-^™)  =  '50  dioptry.  If  we  wish  to 
find  the  focal  distance  of  a  lens  of  this  system  we  re- 
verse the  fraction.  Thus  a  lens  otlD  =  \  =1  metre  ; 
one  of  2  D  =  ^  =  ^  metre.  As  the  degree  of  ametro- 
pia is  expressed  by  the  lens  which  corrects  it,  the  sev- 


SUPPLEMENT.  171 

eral  degrees  of  refractive  error  are  indicated  in  diop- 
tries.  Thus,  if  by  the  old  system  H  =  ■^^,  by  the  new 
H  =  1.  D  ;  and  if  M  =  ^  old,  M  =  2.  D  new ;  M  ^^  = 
3.  D. 

A  given  number  of  dioptrics  may  be  reduced  to  the 
old  numbers  by  dividing  by  40  (40  inches  being  nearly 
1  metre).  Thus  1.  D  ^  40  =  ^V ;  2.  D  -^  40  =  ^ ;  3. 
D  -T-  40  =  3^ ;  and  reversely  the  old  numbers  may  be 
reduced  to  the  new. 

Applying  the  principles  of  the  test-types  and  lenses 
to  the  examinations  of  difficulties  of  refraction  and 
accommodation,  we  shall  be  able,  in  a  given  case,  to 
apply  lenses  which  shall  serve  to  reveal  objects  clearly 
at  a  distance,  or  assist  vision  for  reading  and  -vvTiting, 
as  the  case  may  demand. 

In  determining  the  defects  in  refraction  the  exam- 
iner should  first  carefully  inspect  the  general  appear- 
ance of  the  eye,  observing  its  form  and  relation  to  its 
fellow,  as  well  as  any  indication  of  clouds  upon  the 
surface  of  the  cornea  or  of  opacities  behind  the  pupil. 
The  acuteness  of  vision  should  be  tested  without  the 
aid  of  glasses,  and  again  with  glasses.  The  condi- 
tion of  the  interior  of  the  eye  should  be  carefully  de- 
termined by  the  aid  of  the  ophthalmoscope,  and  evi- 
dences of  imperfection  in  the  refracting  media  or  of 
disease  of  the  deep  structures  carefully  noted. 

In  the  diagnosis  of  ametropia  the  ophthalmoscope 
and  various  optometers  may  be  used.  In  practice, 
however,  a  case  of  trial-glasses  is  absolutely  necessary. 
With  a  view  of  furnishing  a  portable  and  compara- 
tively inexpensive  case  of  trial-glasses,  such  as  may 


172  FUNCTIONAL  NERVOUS  AFFECTIONS. 

be  fully  equal  to  the  requirements  of  the  general  prac- 
titioner, but  which  does  not  include  glasses  unneces- 
sary except  after  cataract  operations  or  in  rare  cases, 
the  author  has  devised  a  case  which  he  believes  fully 
meets  the  requirements. 

The  object  is  attained  by  including  in  a  single  set 
of  lenses  all  those  numbers  more  commonly  in  use. 
All  the  numbers  of  spherical  lenses  contained  in  Na- 
chet's  large  case  up  to  10.  D  (old  No.  4),  are  retained, 
with  such  other  glasses  as  are  best  calculated  to 
produce  all  the  higher  denominations  with  the  least 
trouble.  By  combining  not  more  than  two  lenses  at 
one  time,  all  the  numbers  of  the  best  trial  cases  may 
be  readily  obtained.  A  similar  arrangement  holds  in 
regard  to  cylindrical  lenses.  IN'umbers  frequently  re- 
quired correspond  to  those  of  the  most  complete  trial 
cases,  while  all  the  others  can  be  obtained  with  perfect 
ease  by  simple  combinations. 

The  lenses  are  constructed  upon  the  metrical  sys- 
tem ;  hence,  combinations  can  be  made  without  any 
complex  mathematical  calculations. 

The  case  also  contains  a  set  of  prismatic  glasses, 
opaque  and  stenopaic  disks,  plain  and  colored  glasses, 
and  an  adjustable  trial-frame.  With  this  trial  case,  all 
the  examinations  in  regard  to  refractive  conditions  or 
muscular  anomalies  can  be  made  as  conveniently  as 
with  the  most  complete  and  expensive  case. 

If  the  examiner,  being  provided  with  suitable  trial- 
glasses,  wishes  to  ascertain  the  refractive  condition  of 
the  eye  to  be  examined,  he  excludes  the  other  eye  from 
the  act  of  vision  by  i)lacing  in  his  trial-frame  an  opaque 


SUPPLEMENT.  173 

disk,  or  by  any  suitable  device.  The  person  examined 
is  now  requested  to  read  tlie  letters  of  the  trial-card, 
and  the  extent  to  which  the  letters  are  seen  is  noted. 
If  the  letters  of  No.  XX  are  read  at  twenty  feet,  we 
conclude  that  myopia  does  not  exist,  and  we  are  to  de- 
termine the  presence  or  absence  of  hyxDeropia  or  a  mod- 
erate degree  of  astigmatism.  The  myopic  vision  is 
unable  to  adjust  by  accommodation  for  a  distant  point, 
but  one  in  whom  the  faculty  of  accommodation  is  ac- 
tive may  conceal  a  low  degree  of  astigmatism  or  a  high 
degree  of  hyperopia.  If  the  patient  sees  as  well  with 
a  convex  glass  of  any  denomination,  as  without,  mani- 
fest hyiDeropia,  equal  to  the  strongest  glass  thus  ac- 
cepted is  proved.  But  let  us  suppose  that  the  type  of 
'No.  XXX  is  read,  and  that  No.  XX  can  not  be  clearly 
made  out.  Vision  is  then  f  f ,  and  if  no  disease  or  ob- 
struction exists  it  may  be  hoped  that  vision  can  be 
raised  to  f-g^.  First,  a  very  weak  convex  spherical  glass 
(•50  D)  is  placed  before  the  eye  ;  if  vision  is  somewhat 
improved,  a  stronger  and  stronger  may  be  tried,  until 
the  best  results  are  attained.  But,  before  the  eye  be- 
comes fatigued,  the  effect  of  a  weak  convex  cylindrical 
glass  should  be  compared  with  that  of  the  spherical. 
The  cylindrical  glass  should  be  placed  in  various  posi- 
tions before  it  is  rejected.  If  the  convex  si)herical  aids 
vision  and  the  cylinder  does  not,  to  an  equal  extent, 
simple  hyperopia  is  to  be  assumed.  In  case  neither 
the  convex  spherical  nor  cylindrical  lens  aids  vision, 
but  rather  renders  the  characters  indistinct,  concave 
spherical  and  then  cylindrical  glasses  are  to  be  tried  in 
the  same  manner.     In  case  neither  assists  the  eye,  we 


174  FUNCTIONAL  NERVOUS  AFFECTIONS. 

are  to  assume  that  no  refractive  error  exists,  unless, 
with,  the  ophthalmoscope,  we  are  able  to  discover  the 
refractive  anomaly.  We  have  emmetropia  with  but  |^ 
vision. 

If  the  eye  subjected  to  examination  is  hyperopic, 
and  is  fully  under  the  influence  of  atropine,  the  abso- 
lute hyperopia  may  be  discovered  ;  otherwise,  we  can 
determine  only  the  manifest  refractive  error. 

The  strongest  glass  which  is  found  to  give  addition- 
al sharpness  of  detail  to  the  letters  represents  the  de- 
gree of  manifest  or  absolute  hyi^eroi^ia,  as  the  case  may 
be.  It  is  not  to  be  forgotten  that  when  atropine  or 
some  other  mydriatic  is  not  used,  a  certain  amount  of 
hyperopia  may  remain  latent ;  that  the  sum  of  the 
manifest  and  latent  hyperopia  equals  the  total.  Hy- 
peropia which  may  be  latent  at  one  time  may  become 
manifest  at  another.  Hence  the  glass  which  appears 
to  correct  the  manifest  refractive  error  at  one  time  may 
be  found  at  a  later  time  to  be  too  weak. 

If  a  convex  glass  of  1*00  D  corrects  the  absolute  hy- 
peropia, then  H  =  1  "00  D  ;  but  if  it  is  only  the  manifest 
hyperopia  of  an  eye  which  may,  under  the  circum- 
stances, exercise  its  accommodation,  Hm  =  l-OOD. 

The  question  of  the  extent  to  which  glasses  should 
be  used  in  hyperoi)ia  is  an  important  one. 

Theoretically,  the  accommodation  should  be  re- 
lieved from  all  but  the  amount  of  exercise  which 
would  be  required  in  emmetropria,  but  practically  it  is 
found  more  convenient,  in  many  instances,  to  allow 
the  eye  to  subject  itself  to  a  certain  amount  of  accom- 
modative effort  at  a  distance. 


SUPPLEMENT.  I75 

Children  with  moderate  hyperopia  need  not,  as  a 
general  rule,  use  glasses  for  distance.  But  if  an  in- 
sufficiency of  some  of  the  ocular  muscles  exists,  there 
may  be  an  advantage  in  their  use  even  for  distance. 
If  the  child  suffers  from  nervous  complications,  such, 
for  instance,  as  chorea  or  headaches,  it  may  also  be 
advisable  to  employ  the  glasses  habitually.  In  other 
cases  a  glass  of  rather  less  strength  than  corrects  the 
absolute  hyperopia  is  to  be  used  for  near  work.  In 
high  grades  of  hyperopia,  or  in  case  of  loss  of  accom- 
modation from  age  or  other  cause,  the  hyperopia  should 
be  corrected  for  aU  distances. 

After  the  age  of  forty-five  or  fifty,  most  hyperopic 
persons  will  require  two  pairs  of  glasses :  one  for  cor- 
recting the  hyperopia,  to  be  used  for  the  distance ;  the 
other  stronger,  neutralizing  both  the  hyperoi^ia  and 
presbyopia. 

Let  us  suppose  that,  in  the  case  already  assumed,  a 
convex  glass  does  not  improve  but  rather  dulls  vision 
at  the  distance  of  twenty  feet,  and  that  a  concave  glass 
serves  to  render  the  letters  of  the  trial-card  more  dis- 
tinct. Myopia  is  to  be  assumed,  and  the  weakest  con- 
cave glass  giving  the  most  distinct  vision  at  twenty 
feet,  the  accommodation  being  relaxed,  represents  the 
degree  of  myopia.  In  determining  the  degree  of  myo- 
pia, we  begin  by  selecting  a  glass  of  low  and  gradually 
of  higher  power,  until  the  lens  affording  the  greatest 
improvement  in  vision  is  found.  We  may  form  an  ap- 
proximate conclusion  in  respect  to  the  degree  of  myo- 
pia by  finding  the  greatest  distance  at  which  ordinary 
print  can  be  read.    We  estimate  the  distance  at  which 


176  FUNCTIONAL  NERVOUS  AFFECTIONS. 

the  page  becomes  indistinct,  wliicli  indicates  the  far 
point  of  vision.  If  this  is  less  than  the  distance  at 
which  the  same  page  would  be  read  by  the  emmetropic 
eye,  myopia  is  presumed. 

If  the  distant  point  for  reading  the  type  'No.  '50  be 
one  fourth  of  a  metre  (about  ten  inches),  we  have,  ap- 
proximately, myopia  4*00  D,  or  ■^.  "VVe  may  now  try 
the  effect  of  a  negative  glass  of  4*00  D  (of  the  old  system 
No.  10),  generally  with  the  effect  of  enabling  the  letters 
to  be  carried  to  the  distance  of  half  a  metre,  and  of 
materially  improving  vision  at  the  distance  of  twenty 
feet.  We  now  seek  for  the  weakest  glass  that  will  en- 
able the  patient  to  see  well.  It  is  not  to  be  forgotten 
that  the  strongest  convex  glass  with  which  the  patient 
can  see  well  at  a  distance,  and  the  weakest  concave 
glass  with  which  vision  is  not  less  acute  than  with 
those  of  stronger  power,  represent  respectively  the 
manifest  hyperopia  and  the  grade  of  myopia. 

If,  now,  in  the  case  above  supposed,  we  can  obtain 
a  slight  increase  of  vision,  or  even  equal  vision,  by  plac- 
ing in  front  of  the  4*00  D  lens  a  weak  convex  glass, 
say  of  -j-  '50,  our  correcting  glass  is  too  strong,  and 
must  be  reduced  to  the  extent  of  the  value  of  the  sec- 
ond glass.  On  the  contrary,  if  a  weak  concave  glass 
assists,  we  must  increase  the  strength  of  the  original 
glass  in  a  corresponding  degree. 

In  practice,  the  subject  of  myopia  should  always 
use  the  full  correcting  glasses  for  distant  seeing,  but 
this  may  be  less  convenient  for  near  work.  The  ac- 
commodation is  often  enfeebled  in  myopia,  and  the 
effort  at  adjustment  for  near  points,  such  as  would  be 


SUPPLEMENT.  I77 

required  for  the  emmetropic  eye,  may  become  wea- 
risome. In  this  case  glasses  should  be  used  of  less 
strength  than  those  demanded  for  distance,  or  if  the 
myopia  is  of  but  very  moderate  degree,  glasses  may  be 
left  off  in  reading.  Again,  if  the  distance  at  which  the 
eyes  are  to  be  used  is  such  that  the  individual  does  not 
see  well  without  glasses,  and  is  fatigued  by  the  use 
of  those  employed  for  distance,  we  may  reduce  the 
strength  of  the  glass  according  to  the  distance  required. 
Thus,  if  the  distance  is  that  for  ordinary  reading  (about 
one  half  metre),  we  reduce  the  glass  2*00  D  ;  but  if  the 
glass  is  required  for  a  somewhat  greater  distance,  as  for 
instance  by  a  public  speaker  who  wishes  to  refer  to  his 
notes,  or  by  one  who  would  read  music  at  a  piano,  we 
estimate  the  distance  at  about  thirty  inches,  or  three 
fourths  of  a  metre,  and  deduct  from  the  strength  of 
our  glass  1*33  D,  or,  in  practice,  1'50.  We  find  the 
amount  of  such  deductions  by  dividing  1  by  the  dis- 
tance in  decimals  of  a  metre.  Thus,  for  one  half  metre, 
i^  =  2-00  and  1^=1-33.  As  the  nearest  approxi- 
mate number  to  this  last  in  the  trial-cases  is  1"25  or  1-50, 
we  may  select,  according  to  the  case,  the  stronger  or 
weaker  number. 

The  determinations  of  refraction  are  not  always  as 
easy  as  in  cases  of  simple  hyperopia  or  myoi^ia.  In  a 
very  considerable  proportion  of  cases  of  anomalous  re- 
fraction astigmatism  exists.  This  may  render  the  diag- 
nosis of  the  precise  refractive  error  extremely  difficult, 
and  much  practice  and  skill  may  be  required  in  arriv- 
ing at  a  proper  result.  The  general  rules  for  determin- 
ing astigmatism  are  not  so  complex  that  they  may  not 


178 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


Fig.  10.- 


-Dr.  Snellen's  test-lines  for  astig- 
maliaui. 


be  understood  without  much  difficulty,  but  in  practice 
the  examiner  will  often  find  that  he  must  rely  largely 
upon  his  own  tact  and  experience  rather  than  upon 
fixed  rules.  The  tests  for  astigmatism  depend  upon 
the  fact  that  an  astigmatic  eye,  in  looking  at  lines 
drawn  at  different  angles  with  the  horizon,  sees  some 
lines  more  clearly  than  others.  On  this  principle,  the 
fan  of  Snellen  and  the  radiating  lines  of  Green  are  con- 
structed. A  reduced 
copy  of  each  is  here 
represented.  The 

thickness  of  the  lines 
is  made  to  correspond 
with  the  thickness  of 
the  limbs  of  the  let- 
ters of  the  test-types 
for  twenty  feet. 

After  satisfying 
ourselves  that,  in  the 
case  to  be  examined, 
there  is  an  absence  of 
disease  of  the  inte- 
rior of  the  eye  and  of 
obstructions  to  the 
passage  of  light,  tests 
for  hyperopia  and  myopia  are  made. 

The  examiner  having  ascertained  whether  either  of 
these  conditions  exists,  corrects  any  hyperopia  or 
myopia  which  may  be  found  with  a  convex  or  concave 
glass,  as  the  case  may  be.  If  neither  of  these  con- 
ditions is  found,  no  spherical  glass  will  be  required. 


Fig.  11. — Dr.  Green's  test-lines. 


SUPPLEMENT.  I79 

If,  then,  there  remains  a  defect  of  vision,  the  patient 
is  required  to  state  whether  the  radiating  lines  are 
all  seen  equally  well.  If  one  line  or  group  of  lines 
is  seen  with  greater  clearness  than  the  others,  this 
line  indicates  the  meridian  of  the  eye  in  which  the 
fault  is  to  be  found.  K  the  lines  of  Dr.  Green  are 
used,  we  inquire,  first,  respecting  the  contrast  between 
the  vertical  and  the  horizontal  group.  As  these  bear 
the  numbers  of  a  clock-dial,  we  find,  for  instance, 
whether  the  group  from  XII  to  VI  is  more  or  less 
clearly  seen  than  the  group  from  III  to  IX,  or,  in  other 
words,  whether  the  vertical  is  more  distinct  than  the 
horizontal,  and  many  like  questions,  if  need  be,  in  or- 
der to  understand  the  location  of  the  contrasting 
groups.  Having  learned  that  one  group  of  lines,  for 
instance,  that  from  III  to  IX,  is  most  clearly  seen, 
the  examiner  places  a  cylindrical  lens  before  the  eye 
with  its  axis  at  right  angles  with  the  line  best  seen,  in 
this  case  vertically,  or,  as  marked  on  the  scale  of  the 
trial-frame,  at  90°.  A  convex  or  a  concave  spherical 
glass  may  now  be  found  which  will  render  this  horizon- 
tal line  as  clearly  visible  as  the  line  at  right  angles  to 
it  was  at  first,  and  the  value  of  this  glass  will  represent 
the  difference  of  refraction  of  the  two  meridians.  Or, 
a  convex  cylinder  may  be  first  used,  when,  if  it  proves 
unsatisfactory,  a  concave  cylinder  of  low  power  is 
tried. 

If,  with  a  convex  cylinder  of  low  power,  with  its 
axis  at  a  right  angle  to  the  line  most  clearly  defined, 
the  diagram  appears  in  aU  respects  more  plainly  visi- 
ble and  more  uniform,  we  have  hyperopic  astigmatism. 


180  FUNCTIONAL  NERVOUS  AFFECTIONS. 

If,  on  the  contrary,  a  concave  cylinder  similarly 
placed  is  demanded  to  improve  the  clearness  and  uni- 
formity of  the  lines,  we  have  myopic  astigmatism. 

In  either  case  the  strength  of  the  cylindrical  glass 
which  renders  the  lines  most  perfectly  seen  in  all 
meridians  represents  the  degree  of  astigmatism.  The 
diagnosis  of  a  low  or  moderate  grade  of  myopic  as- 
tigmatism in  a  young  person  should  not  be  accepted  if 
atropine  is  not  used. 

The  test-letters  should  now  be  brought  into  requi- 
sition, and  if,  with  the  glass  selected,  the  best  possi- 
ble vision  is  obtained,  it  is  the  glass  to  be  ordered  for 
constant  distant  use  and  for  all  purposes,  if  pres- 
byopia does  not  exist.  Much  may  be  gained  in  certain 
cases  by  varying  the  strength  of  the  glass  while  exam- 
ining with  the  test-letters,  and,  in  case  that  both  a 
spherical  and  a  cylindrical  lens  may  be  demanded,  we 
may  alternately  weaken  or  strengthen  one  at  the  ex- 
pense of  the  other. 

In  case  of  the  demand  for  both  spherical  and  cylin- 
drical lenses,  we  have  compound  astigmatism.  In  this 
case  we  first  find  the  spherical  glass  which  will  render 
one  line  clear,  then  leaving  this  glass  in  place  we  test 
for  the  cylindrical,  which  will  render  the  ray  at  right 
angles  to  it  clear. 

In  mixed  astigmatism  the  correction  is  first  made 
either  by  a  spherical  glass,  as  above  directed,  when  a 
cylindrical  glass  of  opposite  refracting  quality  is  used 
to  correct  the  opposite  meridian.  If,  for  example,  a 
convex  spherical  glass  of  I'OO  D  corrects  the  horizontal 
meridian,  while  a  concave  spherical  of  1*00  D  renders 


SUPPLEMENT.  181 

the  vertical  line  most  distinct,  we  may,  in  this  case,  use 
a  convex  spherical  of  1"00  D,  combined  with  a  concave 
cylindiical  equal  in  strength  to  the  spherical,  together 
with  the  degree  of  myopic  astigmatism,  that  is,  of  2*00 
D  with  its  axis  horizontally  ;  otherwise  we  may  emj)loy 
a  convex  cylindrical  glass  of  1"00  I)  with  its  axis  verti- 
cal, combined  with  a  concave  cylindrical  glass  of  1"00  D 
with  its  axis  horizontal.  These  two  combinations  will 
produce  practically  the  same  result,  and  will  make  all 
parts  of  the  diagram  equally  distinct,  and  hence  effect 
a  correction  of  the  astigmatism. 

It  is  evident  that  glasses  for  the  correction  of  astig- 
matism must  not  only  be  ground  to  meet  the  indica- 
tions of  the  unequal  errors,  but  that  they  must  be 
accurately  placed  before  the  eye  in  order  to  correct  the 
proper  meridians.  The  frames  which  accompany  the 
best  boxes  of  trial-glasses  are  supplied  with  a  scale  on 
which  is  engraved  the  degrees  of  a  half-circle,  by  which 
the  examiner  is  enabled  to  determine  and  prescribe  the 
position  of  the  axis  of  each  glass.  Certain  signs  are, 
for  convenience,  employed  by  oculists  in  prescribing 
or  recording  the  elements  of  compound  glasses.  Let 
it  be  required  to  prescribe  a  glass  composed  of  the 
following  elements  :  Spherical  -f  I'OO  D  combined  with 
cylindrical  -f  0-75  D,  with  its  axis  at  90°,  we  write : 
S  +  1  -00  C  cyl.  +  0  -75,  90°. 

If  two  cylinders,  a  convex  and  concave,  are  to  be 
combined,  convex  2-00  D  at  90'',  with  concave  1-50  D  at 
1-80°,  we  write: 

cyl.  +  2-00,  90°  [cyl.  -  I'SO,  1'80°. 

The  method  of  examination  described  above  is  a 


182  FUNCTIONAL  NERVOUS  AFFECTIONS. 

conyenient  one,  but  is  only  one  of  several  which,  may- 
be used,  according  to  the  inclination  of  the  oculist. 

Astigmatic  eyes  are  often  poor  eyes,  and  vision  is, 
in  some  cases,  only  moderately  improved  by  correc ting- 
glasses  at  first,  although  in  a  certain  proportion  of 
cases  marked  improvement  may  be  observed  after 
several  months. 

UNEQUAL   REFKACTION  OF  THE  ETES  (ANISOMETROPIA). 

It  is  not  uncommon  to  find  a  difference  in  the  re- 
fraction of  the  two  eyes.  One  eye  may  be  emmetropic 
and  the  other  myopic,  hyperopic,  or  astigmatic,  or 
there  may  be  different  degrees  of  ametropia  in  the  two 
eyes. 

If  the  difference  is  small,  it  is  best  to  correct  the 
error  of  each  eye.  If,  however,  there  is  great  dispari- 
ty of  the  refractive  conditions,  much  difficulty  may  be 
experienced  by  the  patient  in  trying  to  correct  both. 
In  such  cases  there  is  usually  found  very  marked 
anomalous  tendencies  of  the  ocular  muscles  which 
seriously  complicates  the  situation.  Before  glasses 
perfectly  adapted  to  each  eye  can  be  used  with  com- 
fort in  such  extreme  cases,  it  is  necessary  to  establish 
muscular  equilibrium,  after  which  there  is  a  better 
prospect  of  harmonious  action  of  the  two  eyes. 

TREATMENT   OF   PRESBYOPIA. 

It  has  already  been  shown  that  presbyopia  consists 
of  the  gradual  recession  of  the  near  point  of  clear 
vision  toward  the  distant  point.  At  the  age  of  forty- 
five,  owing  not  to  the  flattening  of  the  eyeball,  as  has 


SUPPLEIklENT.  183 

been  popularly  supposed,  although  a  slight  change  in 
the  length  of  the  axis  of  the  eye  actually  occurs,  but 
to  the  loss  of  elasticity  of  the  crystalline  lens,  the  em- 
metropic eye  finds  some  difficulty  in  reading  fine  type, 
especially  in  the  evening.  According  to  Bonders, 
the  near  point  of  clear  vision  in  the  emmetropic  eye 
is,  at  the  age  of  ten,  two  and  two- thirds  inches  in  ad- 
vance of  the  eye  ;  at  twenty  it  is  three  and  a  half ;  and 
at  forty  a  little  more  than  eight  inches  removed  from 
the  front  of  the  eye.  There  is,  then,  no  absolute  point 
where  the  change  to  presbyopia  commences,  and  the 
selection  of  a  point  which  shall  be  regarded  as  presby- 
opia is  entirely  arbitrary,  based  upon  the  needs  of  the 
great  majority  of  those  who  require  glasses  on  account 
of  advancing  age.  Bonders  fixes  the  point  of  com- 
mencing presbyopia  as  that  at  which  the  near  point 
has  receded  to  more  than  twenty-two  centimetres,  or 
about  nine  inches  in  front  of  the  eye. 

Adopting  this  as  the  commencement,  we  determine 
the  degree  of  presbyopia  in  a  very  simple  manner.  If 
we  bring  small  letters  (No.  0*5)  toward  the  eye  until 
we  find  the  nearest  point  of  clear  vision,  we  calculate 
the  difference  between  this  point  and  the  point  of  com- 
mencing presbyopia ;  thus : 

Presbyopia  =  -^  —  l. ;  n  in  the  formula  represents 
the  near  point  ascertained.  ltn  =  12  inches,  then  the 
formula  reads : 

P  =  i  -  iV  =  ^. 

Presbyopia  then  =  -gig-,  and  a  glass  of    thirty-six 

inches  focal  length  is  required  to  bring  the  near  point 

to  nine  inches. 
13 


184 


FUNCTIONAL  NERVOUS  AFFECTIONS. 


Substituting  the  metrical  system,  in  wMcli  a  lens 
with  the  focal  value  of  nine  inches  is  represented  by 
4 '50  D,  and  one  of  twelve  inches  by  3*25  D,  and  our 
formula  will  be 

4-50 -3-25  =  1-25. 

The  following  table  indicates  the  lenses  which, 
according  to  Bonders,  are  required  for  presbyopia  of 
emmetropia  at  different  ages : 


Age. 

D 

Inches. 

Ago. 

D 

iDches. 

45 

1-00 

V.0 

66 

4-50 

v« 

50 

2-00 

%o 

TO 

5-50 

Vt 

55 

3-00 

Vl3 

75 

600 

VeH 

60 

4-00 

Vio 

80 

7-00 

'k^ 

It  must  not  be  supposed  that  every  pair  of  emme- 
tropic eyes  will  find  these  glasses  exactly  suited  to  the 
necessities  of  close  work.  The  distance  at  which  work 
is  to  be  done  is  to  be  considered  in  the  selection  of 
the  glasses ;  thus  a  public  speaker  who  reads  his 
notes  while  speaking  will  require  glasses,  other  circum- 
stances being  equal,  weaker  than  one  who  works  at  a 
desk.  Again,  vision  of  emmetropic  eyes,  through  the 
influence  of  muscular  insufficiences  or  other  causes, 
is  not  unfrequently  less  than  the  normal  standard. 
Hence,  glasses  must  be  adapted  especially  to  the  indi- 
vidual. 

It  is  evident  that  if  hyperopia,  myopia,  or  astigma- 
tism exists,  either  condition  must  be  taken  into  con- 
sideration. If  hyperopia  exists,  the  amount  must  be 
added  to  the  degree  of  presbyopia  shown  in  the 
table.    If  myopia  is  present,  it  is  to  be  deducted ;  and 


SUPPLEMENT.  185 

in  a  case  of  astigmatism,  the  value  of  the  correcting 
cylinder  is  to  be  added  or  subtracted. 

In  determining  the  glasses  required  in  an  individ- 
ual case  we  employ  test-types.  Those  in  most  general 
use  for  this  purpose  are  Snellen's.  These  types  are 
so  graduated  as  to  represent  the  greatest  distance  at 
which  they  should  be  read.  Thus  the  smallest  (see 
page  169),  0*5  D,  should  be  read  at  one  half  metre 
(eighteen  inches),  the  fourth  at  one  metre  (forty  inch- 
es), and  the  sixth  at  l"oO  metre. 

In  testing  presbyo]Dia,  we  first  correct  the  amme- 
tropia  by  placing  the  proper  glasses  in  the  trial-case. 
The  patient  is  then  required  to  read  the  smallest  types 
which  can  be  read,  and  the  nearest  and  farthest  points 
are  noted.  In  practice  it  is  advisable  not  to  force  the 
eyes  to  read  the  smallest  type  at  nine  inches,  but  at  a 
somewhat  greater  distance ;  twelve  inches  may  be  ac- 
cepted. If  the  patient,  in  holding  the  card  at  twelve 
inches  in  front  of  the  eyes,  is  able  to  read  the  types 
marked  1"25,  and  none  smaller  at  this  distance,  we 
may  place  glasses  of  1-25  D  in  the  frames.  It  will 
now  be  found  that  No.  '50  can  be  read  at  twelve  inches. 
The  type  is  then  to  be  removed  to  the  distance  indi- 
cated by  the  number  O'oO  (eighteen  inches),  and  if  it 
can  still  be  read  at  this  distance,  there  is  a  reasonable 
amplitude  of  accommodation,  and  the  glasses  are  not 
too  strong. 

If  the  patient  is  quite  myopic,  the  fully-correcting 
concave  glasses  may  be  left  out  of  the  trial-frames,  and 
the  weaker  glass,  which  will  permit  the  small  types  to 
be  read  at  the  specified  distance,  may  be  chosen. 


186  FUNCTIONAL  NERVOUS  AFFECTIONS. 

In  concluding  this  sketcli  of  the  subject  of  refrac- 
tion and  accommodation,  it  will  not  be  out  of  place  to 
call  attention  to  some  general  points  of  interest  which 
are  incidentally  related  to  the  subject. 

Ametropic  eyes  —  eyes  varying  from  the  ideal 
standard — are  very  common.  It  is  an  ordinary  oc- 
currence for  the  oculist  to  find  persons  who  believe 
that  they  are  blessed  with  the  best  of  vision,  and 
who  boast  of  its  excellence,  to  have  really  quite  de- 
fective eyes,  and  perha^DS  very  indifferent  vision.  To 
assume  that  one  has  excellent  eyes  because  the  name 
of  a  distant  steamboat  can  be  read  by  the  possessor 
when  others  do  not  read  it,  or  because  the  letters  of  a 
sign-board  are  seen  when  one's  neighbor  does  not  read 
them,  is  to  presume  that  all  the  other  persons  who 
may  be  looking  at  these  objects  have  perfect  eyes,  and 
that  their  attention  has  been  equally  directed  to  the 
object.  Such  tests  prove  nothing,  and  should  not  lead 
one  to  assume  a  perfection  which  may  not  exist. 

A  very  popular  error  is  the  supposition  that  one 
must  have  "strong"  eyes  because  their  possessor  is 
able  to  see  small  objects  better  than  others,  and  such 
a  person  is  likely  to  boast  of  the  ability  of  one  or 
both  parents  to  read  without  glasses  until  at  an 
advanced  age.  It  has  been  shown  already  that,  when 
people  who  have  passed  the  age  of  fifty  are  able  to  read 
without  glasses,  it  is  an  indication,  not  of  perfect  eyes, 
but  of  myopia ;  and  when  peoj^le  see  minute  objects 
better  than  usual,  we  also  conclude  that  they  are  near- 
sighted. 

Many  people  who  have  refractive  or  muscular  disa- 


SUPPLEMENT.  187 

bilities  suffer  from  a  certain  degree  of  intolerance  of 
light.  To  avoid  tlie  inconvenience  arising  from  ordi- 
nary dayliglit,  it  is  a  not  uncommon  practice  to  em- 
ploy tinted  glasses.  It  is  even  the  practice  of  some 
oculists  to  prescribe  such.  The  practice  is  not  one  to 
be  commended.  If  the  ej'es  do  not  tolerate  the  light, 
the  reason  for  the  intolerence  should  be  learned  and 
removed.  Proper  attention  to  the  refractive  or  muscu- 
lar states  will,  in  the  great  majority  of  instances,  afford 
complete  relief. 

In  case  of  disease  of  the  eye,  or  in  facing  extreme 
light,  colored  protectors  may  be  of  temporary  advan- 
tage. 

The  material  of  which  lenses  should  be  made,  and 
the  manner  in  which  they  should  be  adapted  to  the 
face,  are  subjects  worthy  of  consideration. 

Many  people  suppose  that  "pebbles"  or  lenses 
made  of  rock-crystal  are  much  better  than  those  made 
of  glass.  This  is  a  popular  error.  The  crystal  has 
only  the  advantage  of  greater  hardness,  while  it  has 
the  disadvantage  of  greater  expense,  and  is  very  often 
less  perfect  optically  than  the  glass  lens. 

Glasses  should  be  so  adjusted  to  the  face  as  to  bring 
them  in  proper  relation  to  the  eyes.  Formerly  nearly 
all  eye-glasses  were  so  made  as  to  hang  downward 
upon  the  face,  greatly  interfering  with  the  symmetry 
of  the  facial  lines,  and  forcing  the  eyes  to  look  through 
the  borders  of  the  glasses. 

Recently  much  improvement  has  been  made  in  this 
respect.  Such  glasses  should  be  made  to  permit  the 
light  to  pass  directly  through  the  optical  center  of  the 


188  FUNCTIONAL  NERVOUS  AFFECTIONS. 

glass  to  tlie  pupil.  The  borders  should  correspond 
with  the  lines  of  the  brows.  The  glasses  should  be 
large,  and  the  frames  should  not  be  conspicuous. 
Under  these  circumstances  the  natural  expression  of 
the  face  is  not  interfered  with,  and  the  glasses  are 
much  less  conspicuous  than  when  the  facial  lines  are 
broken  up. 

There  is  a  general  prejudice  against  the  early  em- 
ployment of  glasses  for  presbyopia.  It  is  thought  that 
the  eye  should  be  forced  to  i^erform  its  function  as  long 
as  possible  without  artificial  assistance.  This,  if  the 
condition  were  one  of  temporary  failure  of  muscular 
tone,  might  be  logical.  In  the  actual  state  of  the  eyes 
such  a  prejudice  is  unwise.  The  eye  in  presbyopia  is 
required  to  exert  an  amount  of  force  which  is  entirely 
inconsistent  with  the  well-being  of  the  eye  itself  or  of 
its  possessor.  If  one  persists  in  forcing  the  eyes  to  do 
close  work  without  glasses  after  presbyopia  has  com- 
menced, the  muscular  iDower  fails,  and  presbyopia  in- 
creases more  rapidly  than  if  pro^Der  relief  is  given  at 
the  right  time. 

affeotio:n^s   of  the  ocular  muscles  iisr  which  bi- 
nocular VISION  MAY  BE  MAINTAINED. 

In  the  study  of  the  relations  of  ocular  conditions  to 
disturbances  of  the  nervous  system,  the  affections  of 
the  ocular  muscles  occupy  a  position  of  paramount  im- 
portance. 

The  complicated  system  of  muscles  which  co-oper- 
ate in  adjusting  the  two  eyes  in  such  a  manner  as  to 
obtain  binocular  vision  under  a  multitude  of  circum- 


SUPPLEMENT.  189 

stances,  affords  a  subject  of  researcli  attended  oj  diffi- 
culties but  ricli  in  interest. 

In  tlie  act  of  binocular  vision — that  is,  of  vision  in 
whicli  tlie  object  seen  by  tlie  two  eyes  makes  but  a 
single  mental  impression — the  principal  optic  axes  are 
in  such  exact  relation  to  each  other  that  a  straight  line 
drawn  from  the  object  through  the  pupil  falls  upon 
the  yellow  spot  of  the  retina,  the  central  point  of 
vision  of  each  eye,  and  at  the  same  time  each  eye  must 
be  accurately  adjusted  in  respect  to  its  focus  for  the 
distance  from  it  to  the  object  seen. 

With  every  new  adjustment  of  the  eyes  their  rela- 
tions must  be  so  precisely  maintained  as  to  permit  the 
line  from  the  point  seen  to  fall  upon  this  minute  por- 
tion of  the  retina  of  each  eye. 

Such  ever-changing  and  extremely  nice  associated 
actions  are  demanded  in  no  other  part  of  the  organism. 
The  movements  of  the  extremities,  no  matter  how  pre- 
cise or  how  delicate,  make  no  such  constant  demand 
for  minute  precision ;  and  from  no  class  of  muscles, 
other  than  those  that  direct  the  eyes  and  regulate  the 
accommodation,  is  the  maintenance  of  i)erfect  exacti- 
tude of  service  so  constantly  required. 

That  this  exacting  service  should,  when  difficulties 
in  its  performance  are  encountered,  make  excessive 
demands  upon  the  stock  of  nervous  energy  of  the  in- 
dividual, or  result  in  perplexities  or  irritations,  is  not 
surprising. 

Affections  of  the  ocular  muscles  may  be  divided 
into  those  which  result  from  physiological  peculiarities 
and  those  which  result  from  pathological  conditions. 


190  FUNCTIONAL  NERVOUS  AFFECTIONS. 

In  tlie  first  of  these  groups,  the  muscles,  while  mani- 
festing no  indications  of  disease,  do  not  act  in  such 
harmony  as  to  permit  the  most  ready  and  easy  com- 
binations of  action.  This  group  is  divided  into  two 
classes : 

1.  Those  which  permit  of  habitual  binocular  vision. 

2.  Those  in  which  a  blending  of  the  images  of 
the  two  eyes  is  so  difficult  as  to  be,  in  most  instances, 
impossible.  The  conditions  of  this  class  are  known 
under  the  general  term  strabismus. 

The  first  of  these  classes  has  for  a  long  time  been 
known  under  the  name  of  insufficiencies  of  the  ocular 
muscles. 

For  reasons  which  have  been  fully  discussed  else- 
where,* this  term  is  regarded  as  indequate  and  often 
misleading.  It  has  been  shown  that  for  some  of  these 
conditions  no  distinctive  terms  exist,  and  that  to  others 
the  term  insufficiency  is  improperly  applied.  Terms 
of  more  exact  meaning  are  therefore  required. 

Accordingly,  the  system  of  terms  relating  to  the 
conditions,  which  was  suggested  in  the  works  referred 
to,  will  be  employed  here. 

In  this  class  of  muscular  faults,  binocular  vision  is 
maintained  by  the  expenditure  of  a  greater  amount  of 
force  than  is  required  when  the  ocular  muscles  are  in  a 
state  of  perfect  equilibrium.  The  visual  lines  are 
habitually  held  in  such  relations  as  to  extend  from  the 
point  of  fixation  to  the  yellow  spot  of  the  retina,  but 

*  "  Archives  d'Ophthalmologie,"  Paris,  November,  1886 ;  "  New  York 
Medical  Journal,"  December  4,  1886 ;  "  Archives  of  Ophthalmology," 
New  York,  June,  1886. 


SUPPLEMENT.  191 

only  by  persistent  and  special  effort.  The  tendency  is 
for  the  visual  lines  to  part,  for  one  of  them  to  continue 
to  unite  the  fixed  point  and  the  macula  or  yellow 
spot  and  for  the  other  to  fall  upon  some  other  part  of 
the  retina.  Such  tendencies  are  grou^Ded  under  the 
generic  name  Heteeephokia  (eVe/jo?.  different;  (f)6po<;, 
a  tending). 

This  term  includes  the  conditions  which  have  been 
known  as  insufficiencies  of  the  ocular  muscles. 

Some  of  the  most  distinguished  contributors  to  the 
science  of  affections  of  the  eyes  have  given  considera- 
ble attention  to  this  subject,  yet  it  has  received  vastly 
less  consideration  than  its  importance  has  demanded. 
To  Graefe  we  are  greatly  indebted  for  important  re- 
searches in  this  department ;  and  Horner,  Nagel,  Lan- 
dolt,  and  many  others,  have  made  valuable  additions 
to  the  subject.  The  writings  of  Graefe  were  those  of 
a  pioneer  and  were  not  exhaustive.  Others,  however, 
have  been  content  in  great  measure  to  accept  the  re- 
sults of  Graefe's  genius  as  in  the  main  conclusive.  The 
discussion  of  "insufficiencies"  has  been  mainly,  it  may 
be  said  almost  exclusively,  confined  to  a  single  anomaly, 
and  that  not  the  one  of  greatest  importance. 

When  the  eyes  are  directed  to  a  distant  object  situ- 
ated directly  in  front  of  the  observer  and  at  a  distance 
of  from  fifteen  to  twenty  feet,  the  visual  lines  are  prac- 
tically parallel,  and  in  this  position  there  should  be  the 
minimum  of  nervous  energy  directed  to  the  muscles  of 
the  eyes.  If  this  is  the  case,  the  ocular  muscles  are 
said  to  be  in  a  state  of  equilibrium  and  in  all  other  ad- 
justments the  changes  of  relations  required  are  made 


192  FUNCTIONAL  NERVOUS  AFFECTIONS. 

with  the  least  expenditure  of  effort  consistent  with  the 
action. 

This  condition,  in  which  all  adjustments  are  made 
by  muscles  in  a  state  of  physiological  equilibrium,  is 
called  Orthophoria  {6p6o<;,  right;  (f)6po<;,  a  tending). 

In  the  absence  of  orthophoria  there  may  not  be  any 
actual  turning  of  one  visual  line  away  from  the  other, 
but  there  is  a  tendency  on  the  part  of  one  or  more  of 
the  eye-muscles  to  disturb  the  balance.  Should  the 
nervous  control  be  so  removed  as  to  permit  of  the  con- 
summation of  this  tendency,  actual  deviations  would 
occur. 

Such  disturbances  of  equilibrium  are  known,  as 
above  stated,  as  Heteroplioria. 

The  deviating  tendencies  of  heterophoria  may  exist 
in  as  many  directions  as  there  are  forces  to  induce  ir- 
regular tensions. 

The  following  system  of  terms  is  applied  to  the 
various  tendencies  of  the  visual  lines : 

I.  Generic  Terms. — OrthopTioria :  A  tending  of  the 
visual  lines  in  parallelism.  Heteroplioria :  A  tending 
of  these  lines  in  some  other  way. 

II.  Specifio  Terms. — Heterophoria  may  be  divided 
into — 

1.  EsopJioria :  A  tending  of  the  visual  lines  inward. 

2.  ExopTioria:  A  tending  of  the  lines  outward. 

3.  HyperpTioria  (right  or  left):  A  tending  of  the 
right  or  left  visual  line  in  a  direction  above  its  fellow. 

This  term  does  not  imply  that  the  line  to  which  it 
is  referred  is  too  high,  but  that  it  is  higher  than  the 
other,  without  indicating  which  may  be  at  fault. 


SUPPLEMENT.  I93 

III.  Compound  Terms. — Tendencies  in  oblique  di- 
rections may  be  expressed  as  TiyperesopJioria^  a  tend- 
ing upward  and  inward  ;  or  Tiyperexophoria^  a  tending 
upward  and  outward.  The  designation  "right"  or 
"left"  must  be  applied  to  these  terms. 

In  recording  the  respective  elements  of  such  com- 
pound expressions  we  employ  the  sign  1 For  ex- 
ample, if  it  is  desired  to  indicate  that  the  right  visual 
line  tends  above  its  fellow  3°,  and  that  there  is  a  tend- 
ing inward  of  4°,  the  facts  are  noted  thus:  Right 
hyperesopTioria,  3°  l_  4°. 

It  will  be  seen  that  deviating  tendencies  in  every 
possible  direction  can  be  minutely  and  accurately  de- 
scribed by  such  a  system. 

In  seeking  to  discover  these  faulty  tendencies  the 
following  method  will  be  found  convenient,  and  in  the 
majority  of  instances  satisfactory  : 

The  subject  of  examination  is  to  be  seated  with  the 
head  in  what  is  known  as  the  "primary  position,"  in 
which  the  head  is  held  erect  and  the  face  is  turned 
exactly  toward  the  object  to  be  seen,  so  that  a  line 
passing  from  the  object  to  the  face  would  meet  a  line 
drawn  between  the  eyes  at  its  center  and  at  right- 
angles  to  it. 

The  object  to  be  looked  at  should  be  luminous 
against  a  dark  background,  a  lighted  candle  being  the 
best.  It  should  be  nearly  upon  a  level  with  the  eyes, 
and  at  a  distance  of  twenty  feet  from  them.  If  ame- 
tropia exists,  it  is  to  be  corrected  by  appropriate 
glasses. 

Under  these    circumstances  there  should    be   the 


194  FUNCTIONAL  NERVOUS  AFFECTIONS. 

minimum   of    muscular    innervation;    that  is,   ortho- 
phoria should  exist. 

Orthophoria,  or  heterophoria,  may  now  be  deter- 
mined by  means  of  prisms  in  the  following  manner : 

First  of  all,  a  prism  of  sufficiently  high  grade  to  in- 
duce diplopia  is  placed  with  its  base  toward  the  nose 
before  one  of  the  eyes.  The  two  images  of  the  object 
then  seen  are  homonymous — that  is,  the  right  image  is 
seen  with  the  right  eye,  and  the  left  with  the  left  eye. 
If  the  two  images  are  seen  in  exactly  the  same  hori- 
zontal plane,  no  deviating  tendency  in  this  direction  is 
manifest.  If  one  of  the  images  rises  higher  than  the 
other,  there  is  absence  of  equilibrium  in  this  respect, 
and  the  condition  is  the  one  called  JiyperpTioria.  If  in 
the  test  the  left  image  of  the  object  is  seen  higher  than 
the  other,  it  indicates  that  the  visual  line  of  that  eye 
tends  below  that  of  its  fellow,  and  that  the  visual  line 
of  the  right  eye  has,  in  fact,  a  tendency  to  rise  above 
the  left  visual  line.  This  is  right  hyperphoria,  and 
the  state  in  which  the  right  image  is  seen  above  the 
plane  of  the  other  is  known  as  left  hyperphoria. 

If,  as  in  the  first  instance,  the  left  image  is  higher 
than  the  other,  we  determine  the  degree  of  right 
hyperphoria  by  finding  the  grade  of  prism  which, 
placed  with  its  base  down  before  the  right  eye,  or  with 
its  base  up  before  the  left,  will  bring  the  two  images 
exactly  to  the  same  horizontal  plane,  and  the  result 
is  recorded  accordingly.  Thus,  if  a  prism  of  2°  base 
down  before  the  right  eye  corrects  the  deviation  from 
the  horizontal  plane,  we  write 

Right  hyperphoria,  2°. 


SUPPLEMENT.  195 

It  lias  been  said  that  in  determining  the  relations  of 
the  ocular  muscles,  glasses  suitable  for  the  correction 
of  existing  ametropia  should  be  supplied.  In  testing 
for  hyperphoria  this  precaution  is  not  essential,  and 
may,  in  general,  be  neglected,  especially  if  the  correct- 
ing-glasses  should  be  strong.  A  very  slight  variation 
from  exact  adjustment  of  the  optical  centers  of  the 
glasses  to  the  centers  of  the  pupils  might  induce  a  de- 
gree of  apparent  hyperphoria,  which,  if  real,  would 
be  of  considerable  consequence. 

This  test  for  hyperphoria  should  invariably  pre- 
cede all  other  muscular  tests. 

Next,  diplopia  is  induced  by  placing  a  prism,  with 
its  base  exactly  up  or  down,  before  one  of  the  eyes. 
In  general,  a  prism  of  7°  is  sufficient  for  this.  If, 
after  a  moment,  the  images  are  seen  exactly  in  the  ver- 
tical line,  no  deviating  tendency  is  shown.  If,  on  the 
other  hand,  the  upper  image  passes  to  the  right  or 
left  of  the  other,  heterophoria  in  this  direction  is 
shown. 

The  two  deviating  conditions  which  may  now  be 
discovered  are : 

Esophoria  (eW,  within) :  A  tending  of  the  visual 
lines  inward. 

ExojpTioria  (e|,  out) :  A  tending  of  the  visual  lines 
outward. 

If  the  deviations  of  the  images  are  in  the  directions 
of  the  eyes  to  which  they  belong,  the  image  seen  by 
the  right  eye  appearing  most  at  the  right  and  the 
image  seen  by  the  left  eye  at  the  left,  the  tendency 
is  homonymous,  and  esophoria  exists.    If  the  image 


196  FUNCTIONAL  NERVOUS  AFFECTIONS. 

seen  by  tlie  rigM  eye  appears  more  to  the  left  tlian  its 
fellow,  exophoria  is  shown. 

If,  in  making  this  determination,  a  prism  of  7°  is 
placed  with  its  base  down  before  the  right  eye  and  di- 
plopia is  caused,  the  upper  image  will  be  the  one  seen 
by  the  right  eye,  the  lower  that  seen  by  the  left  eye. 

If,  now,  the  upper  image  appears  more  at  the  right 
than  the  lower,  it  indicates  esophoria;  but  if  the 
image  should  be  seen  more  at  the  left  than  the  lower, 
exophoria  would  be  shown. 

In  the  same  manner  as  in  ascertaining  the  degree  of 
hyperxohoria,  Ave  determine  the  degree  of  exophoria  or 
esophoria.  The  prism  which  brings  and  holds  the 
images  in  the  vertical  line  measures  the  defect. 

Should  both  hyperphoria  and  esophoria  or  exo- 
phoria be  found,  the  condition  may  be  described  by 
the  compound  tei-m  hyperesophoria  or  hyperexophoria. 
The  degree  of  each  element  of  heterophoria  is  indi- 
cated thus : 

R.  (or  L.)  Hyperesophoria,  n°  l_  n°. 

If,  in  a  given  case,  it  should  be  found  that  the  right 
visual  line  tends  above  its  fellow  3°,  and  that  the  lines 
tend  inward  4°,  the  facts  are  noted  thus : 
R.  hyperesophoria,  3°  l_  4°. 

The  absence  of  indications  of  heterophoria  does 
not,  of  necessity,  prove  orthophoria.  Heterophoria, 
like  hyperopia,  may  be  latent,  and  considerable  time 
and  much  patience  may  be  required  to  ascertain  the 
true  state  of  the  muscles.  The  conditions  which  are  to 
be  found  by  the  methods  described  are  manifest,  not 
absolute. 


SUPPLEMENT.  I97 

Hence,  hyperphoria  1°  by  the  tests  described  may, 
at  length,  prove  to  be  hyperphoria  3°  or  4°.  The  ten- 
sion at  which  the  eyes  are  habitually  held  may  con- 
tinue in  part  or  entirely  to  conceal  the  absolute  tend- 
encies. 

This  important  fact  that  heterophoria  may  be  mani- 
fest only  in  part  should  not  in  any  case  be  lost  sight 
of.  Many  examinations  may  be  required  to  determine, 
even  approximately,  the  absolute  heterophoria.  In  a 
certain  proportion  of  cases,  latent  heterophoria  may 
become  manifest  by  the  use  of  nominally  correcting 
prisms  in  the  same  manner  as  latent  hyperopia  some- 
times becomes  manifest  after  the  use  of  weak  convex 
glasses.  Great  caution  is  to  be  exercised  in  determin- 
ing the  latent  heterophoria,  that  an  apparent  anomaly 
is  not  actually  induced  by  the  use  of  correcting- 
prisms. 

It  is  possible,  should  one  who  has  perfect  equi- 
librium of  the  eye-muscles  use  prisms  with  the  bases 
out  for  a  few  days,  to  find  the  conditions  of  esophoria 
in  tests  made  immediately  after  removing  the  glasses. 
To  assume  that  such  a  case  is  one  of  actual  esophoria 
would  evidently  be  a  mistake.  But  should  one  who 
manifests  2°  esophoria  use  a  prism  of  1°  for  a  day  or 
two,  and  then  reveal  esophoria  of  3°,  it  would  be  quite 
safe  to  increase  the  prism  to  2° ;  and  should  the  ex- 
cess of  1°  over  the  correction  continue  several  days,  it 
would  be  safe  to  conclude  that  there  is  at  least  3°  eso- 
phoria. 

Having  determined  the  deviating  tendencies  by  the 
methods  described  above,  similar  tests  may  be  made  at 


198  FUNCTIONAL  NEEVOUS  AFFECTIONS. 

reading  distance.  In  these  tests  the  method  of  Graefe 
is  most  conveniently  employed.  On  a  card,  a  fine, 
straight  line  is  drawn  through  a  dot  (Fig.  12).  Diplo- 
pia is  produced  as  before,  but  prisms  of  con- 
siderably stronger  grade  may  be  required,  when 
the  observations  are  made  in  the  same  manner 
as  when  the  test-object  is  situated  at  a  distance. 
This  test  was  used  by  Graefe  for  determining 
"  insufficiency  of  the  interni,"  and  is  the  test 
described  in  text-books.  The  conditions  found 
by  it  may  be  recorded  as  exophoria  (or  eso- 
phoria)  in  accoinmodation.  Exophoria  in  ac- 
FiG  12.  commodation  corresponds  to  the  condition  de- 
scribed by  Graefe  and  others  as  insufficiency 
of  the  interni. 

All  these  determinations  having  been  made  with 
sufficient  care,  the  examiner  proceeds  to  ascertain  the 
relative  power  of  the  different  pairs  of  muscles  by  find- 
ing the  strongest  prism  with  which  images  can  be  unit- 
ed in  different  directions.  To  determine  the  strength 
of  the  abductors,  the  prism  should  be  held  with  its 
base  inward. 

The  standard  of  abduction  adopted  by  the  author  is 
8°.  A  prism  of  that  grade  should  be  overcome,  and 
images  of  an  object  at  twenty  feet  distance  should 
blend.  If  the  abducting  power  is  less  than  this  by  two 
or  three  degrees,  it  is  strongly  suggestive  of  esophoria, 
even  should  esophoria  not  have  been  shown  by  the 
previous  tests. 

It  is  to  be  remembered  that  heterophoria  may  be 
partly  or  wholly  latent,  and  the  fact  that  no  esophoria 


SUPPLEMENT.  I99 

is  manifest  is  to  be  considered  in  its  relation  to  the 
power  of  abduction. 

Deficiency  of  abduction  resulting  from  hyperpho- 
ria will  be  noticed  below. 

The  power  of  overcoming  prisms  with  the  base  up 
or  down  may  be  tried  before  or  after  the  trial  for  ab- 
duction. Commencing  with  a  very  weak  prism,  we 
try  stronger,  until  the  strongest  that  can  be  overcome 
in  one  direction  is  found ;  then  the  strongest  in  the 
opposite  direction.  A  prism  with  its  base  down 
before  one  eye  is  equivalent  in  its  action  to  a  prism 
with  its  base  up  before  the  other.  The  amount  of 
power  shown  in  overcoming  a  prism  with  its  base  down 
before  the  right  eye  is  the  degree  of  right  sursumduc- 
tion.  If  the  prism  is  placed  before  the  left  eye  in  the 
same  direction,  or  if  it  is  turned  with  its  base  up  be- 
fore the  right  eye,  it  indicates  the  degree  of  left  sur- 
sumduction.  We  can  not  make  accurate  determina- 
tions of  both  right  and  left  sursumduction,  if  the  test 
for  one  follows  without  interval  after  the  other.  It  is, 
therefore,  well  to  test  in  one  direction  before  the  test 
for  abduction  and  in  the  other  after  it. 

The  average  ability  of  overcoming  prisms  in  this 
manner  is  about  3°.  In  high  grades  of  myopia  it  may 
reach  8°  or  10°  in  each  direction. 

Finally,  the  amount  of  adduction  is  to  be  deter- 
mined. Prisms  are  to  be  placed  before  the  eyes  with 
the  base  out  and  the  strength  gradually  increased 
until  the  images  can  no  longer  be  blended.  The  high- 
est grade  of  prisms  overcome  marks  the  adducting 
power. 

14 


200  FUNCTIONAL  NERVOUS  AFFECTIONS. 

The  standard  of  adduction  should  be  about  50°,  but 
many,  who  after  trials  repeated  daily  for  two  or  three 
times  will  accomplish  an  adduction  to  this  extent, 
will  not  accomplish  half  the  amount  at  the  first  trial. 

All  the  tests  for  sursumduction,  abduction,  and  ad- 
duction should  be  made  at  the  distance  of  twenty  feet. 

HYPEKPHORIA. 

Hyperphoria  is  that  condition  in  which,  with  the 
ability  to  maintain  binocular  vision,  there  is  a  tending 
of  one  visual  line  in  a  direction  above  that  of  the 
other. 

Strabismus,  in  which  there  is  an  actual  turning  of 
the  axis  of  one  eye  above  the  other  differs  from  hyper- 
phoria in  the  absence  of  ability  to  maintain  single 
vision.  Strabismics  snrsiimvergens,  and  deorsum- 
Tergens  were  described  and  operative  measures  for 
their  correction  were  long  since  pointed  out.  Special 
attention  was  first  called  to  the  condition  of  hyper- 
phoria as  an  important  and  frequent  anomaly  of  the 
ocular  muscles  by  the  author  of  this  work. 

Among  the  anomalous  tendencies  resulting  from 
faults  of  equilibrium  of  the  eye-muscles,  hyperphoria 
is  of  pre-eminent  importance. 

A  slight  deviating  tendency  in  this  direction  is 
often  of  greater  account  than  one  of  a  considerable 
degree  in  others. 

The  ability  of  the  eyes  to  adjust  the  visual  lines  for 
the  correction  of  a  difference  in  their  direction  in  the 
vertical  meridian  is  much  less  than  that  for  correcting 
a  similar  difference  in  the  horizontal  line.     It  has  been 


SUPPLEMENT.  201 

already  shown  that  the  power  to  overcome  a  prism 
placed  with  its  base  up  or  down  before  an  eye  is 
usually  limited  to  about  3°,  while  in  abduction  a  prism 
of  8°  and  in  adduction  prisms  of  50°  may  be  overcome 
when  the  normal  standard  of  power  in  these  directions 
exists.  It  is  evident,  therefore,  that  a  deviating  tend- 
ency of  1°  or  2°  in  the  direction  of  hyperphoria  creates 
an  excessive  demand  for  correction  upon  muscles 
illy  calculated  to  perform  the  duty. 

A  still  more  imi)ortant  element  in  the  results  of 
hyperphoria  is  its  influence  upon  the  action  of  the 
lateral  muscles. 

In  hyperphoria  the  eyes  may  be  so  influenced  in 
their  movements  that,  when  directed  to  a  distant  object 
at  the  same  height  as  the  eyes,  there  is  a  strong  tend- 
ency of  the  visual  lines  inward  (esophoria) ;  but  if 
directed  to  a  near  object,  especially  if  it  is  below^  the 
plane  of  the  eyes,  the  visual  lines  swing  outward,  caus- 
ing a  very  marked  exophoria  in  accommodation,  or,  as 
it  is  familiarly  known,  insufiiciency  of  the  interni. 
Many  of  the  most  intractable  cases  of  insufficiency  of 
the  interni  are  the  result  of  this  swinging  movement  of 
the  eyes,  and  it  is  not  rare  to  see  asthenopic  persons 
who  are  armed  with  powerful  prisms  for  the  correction 
of  insufficiency  of  the  interni,  who  have  no  other 
muscular  error  than  a  slight  hyperphoria. 

Persons  subject  to  hyperphoria  are  much  more 
liable  to  be  troubled  with  double  images  than  those 
subject  to  simple  exophoria  or  esophoria. 

Yertigo  and  confusion  of  vision  are  extremely  com- 
mon symptoms  of  hyperphoria.     Persons  affected  by 


202  FUNCTIONAL  NERVOUS  AFFECTIONS. 

this  anomaly,  if  weak  or  in  ill  liealtli,  often  experience 
a  dread  of  walking  in  crowded  streets  unattended, 
fearing  tliat  tliey  may  fall  or  suffer  from  mental  con- 
fusion in  the  crowd. 

The  attitudes  and  facial  expressions  of  hyper- 
phoria, while  not  universal,  are  quite  characteristic. 
The  head  is,  in  a  very  considerable  proportion  of  cases, 
carried  habitually  toward  one  shoulder.  If  the  right 
eye  tends  higher  than  the  left,  the  head  is  carried  to 
the  left  shoulder;  if  the  left  eye  tends  above,  the  head 
is  at  the  right. 

The  efforts  made  by  the  eyelids  to  aid  in  forcing  the 
eyes  in  position  give  certain  peculiarities  to  the  facial 
expression.  One  eje  may  appear  partly  closed,  or 
both  eyes  are  opened  very  widely  with  a  kind  of  stare 
which  has  been  described  as  "the  hyperphoric  stare." 

The  eyes  in  hyperphoria  have,  in  many  instances, 
an  unsteady  gaze.  One  eye  may  appear  to  float  away 
from  the  other  and  then  back  again. 

Vision  is,  in  a  considerable  proi^ortion  of  cases, 
affected.  It  has  been  found  that,  in  more  than  fifty 
per  cent  of  cases,  vision  is  less  than  two  thirds  the 
normal  standard. 

Many  cases  of  abnornal  secretion  of  tears  have  their 
origin  in  this  condition.  They  do  not  yield  to  the 
ordinary  methods  of  treatment  for  such  comj)laint,  and 
are  liable,  by  means  of  the  excessive  flow  of  tears,  to 
result  in  distention  of  the  lachrymal  sac  and  in  inflam- 
mation of  the  lining  membrane  of  the  nasal  canal, 
leading  to  its  contraction. 

In  its  reflex  results  hyperphoria  is  an  extremely  im- 


SUPPLEMENT.  203 

portant  element  in  neuroses.     Especially  in  epilepsy 
and  vertigo  should  it  be  looked  for  with  great  care. 

TREATMENT   OF  HTPERPHOEIA. 

The  best  treatment  for  hyperphoria  is  tenotomy  of 
the  muscle  which  forces  the  eye  out  of  its  proper  di- 
rection. It  is  not  always  easy  or  even  possible  to  de- 
termine to  which  muscle  we  are  to  attribute  the  vicious 
tendency.  The  superior  rectus  of  one  eye  may  be 
short,  causing  too  great  tension  upward,  or  the  inferior  / 
rectus  of  the  opposite  eye  may  be  at  fault,  tending  to 
draw  the  eye  downward,  or  one  of  the  four  oblique 
muscles  may  cause  the  loss  of  equilibrium.  With  all 
these  elements  of  uncertainty,  the  highest  skill  of  the 
surgeon  may  be  demanded  in  forming  a  correct  con- 
clusion. A  complete  knowledge  of  what  is  known  of 
the  physiological  action  of  the  various  eye-muscles 
is  essential  in  this  examination.  In  the  majority  of 
cases,  however,  in  which  the  hyperphoria  does  not  ex- 
ceed three  degrees,  it  is  proper  to  relax  either  the  supe- 
rior rectus  of  the  eye  of  which  the  deviating  tendency 
is  upward  or  the  inferior  rectus  of  the  other.  In 
general,  it  will  be  found  best  to  select  the  superior 
rectus.  If  more  than  three  or  four  degrees  of  deviat- 
ing tendency  is  found,  it  is  better  to  correct  a  part  up- 
on the  superior  rectus  of  one  eye  and  what  remains  of 
the  defect  upon  the  inferior  rectus  of  the  other  eye 
some  days  later. 

The  method  of  performing  tenotomy  in  these  cases 
of  deviating  tendencies  less  than  strabismus  has  been 

*  See  page  135. 


204  FUNCTIONAL  NERVOUS  AFFECTIONS. 

already  described.*  Since  submitting  this  method  to 
the  Royal  Academy,  however,  I  have  found  it  advisa- 
ble to  modify  the  procedure  somewhat,  rendering  the 
ox)eration  more  simx)le  and  the  results  more  satisfac- 
tory. As  now  performed,  the  eyelids  being  retract- 
ed, a  fold  of  the  conjunctiva  is  seized  by  a  fine  but 
rather  rigid  pair  of  mouse-tooth  forceps,  parallel  with 
the  course  of  the  muscle  and  exactly  over  its  insertion. 
With  a  pair  of  small,  narrow-bladed  scissors,  having 
blunt  but  very  perfectly-cutting  points,  a  transverse 
incision  is  then  made  through  the  membrane  exactly 
corresponding  to  the  line  of  insertion  of  the  tendon. 
The  conjunctival  opening  thus  made  should  not  exceed 
in  extent  one  fourth  of  an  inch.  With  the  forceps 
now  pressing  the  outer  cut  edge  of  the  conjunctiva 
slightly  backward  toward  the  course  of  the  tendon,  the 
latter  is  seized  behind,  but  very  near  its  insertion. 
The  distance  may  depend  upon  the  freedom  with 
which  the  intended  section  of  the  tendon  is  to  be  made. 
But  in  hyperj)horia,  or  in  slight  relaxations  of  the 
lateral  muscles,  a  distance  barely  sufficient  to  allow  a 
small  part  of  the  tendon  to  be  raised  from  the  sclera  is 
all  that  should  be  allowed.  Making  some  tension  now 
with  the  forceps,  the  points  of  the  scissors  are  directed 
against  the  central  jiortion  of  the  tendinous  insertion 
and  toward  the  sclera,  when  a  small  opening  is  made 
dividing  the  center  of  the  tendinous  expansion  exactly 
on  the  sclera.  The  small  opening  is  now  to  be  en- 
larged by  careful  snij)s  of  the  scissors  toward  each 
border,  keeping  more  carefully  on  the  sclera  as  the 
border  of  the  tendon  is  aj)proached.     As  the  section  of 


SUPPLEMENT.  205 

the  tendon  is  carried  toward  the  borders,  the  outer 
blade  of  the  scissors  passes  beneath  the  conjunctiva. 
If  the  relaxation  of  the  tendon  is  to  be  slight,  the  ex- 
treme outer  fibers  of  the  tendon  are  to  be  preserved 
untouched,  but  if  a  considerable  effect  is  desired  these 
fibers  can  be  entirely  severed,  provided  that  the  reflec- 
tion of  the  capsule  of  Tenon  upon  the  tendon  is  not 
disturbed.  By  means  of  the  capsule  acting  as  an 
auxiliary  attachment,  the  tendon  is  held  in  position 
but  is  allowed  to  fall  back  slightly  while  maintaining 
its  relation  to  the  eyeball.  In  this  respect,  and  in  pre- 
serving the  outer  tendinous  fibers,  this  operation  differs 
radically  from  the  ordinary  operation  for  strabismus, 
and  from  any  operation  which  has  been  proposed  for 
so-called  "partial  tenotomy"  of  the  recti  muscles. 

The  judgment  of  the  operator  must  determine  the 
extent  to  which  the  division  should  be  carried  ;  but, 
should  it  be  found  that  too  little  has  been  accom- 
plished, the  section  can  be  extended.  In  doing  this, 
the  use  of  a  very  fine  hook  may  be  advisable.  For 
this  purpose  a  hook  very  much  smaller  and  more  deli- 
cate than  the  ordinary  tenotomy-hook  should  be  em- 
ployed. Its  rounded  point  is  carried  under  the  re- 
maining border  of  the  tendon  vdth  great  care  to  pre- 
vent haemorrhage  or  unnecessary  disturbance  of  the 
conniective  tissues,  the  extension  being  made  toward 
one  and  then  toward  the  other  border,  as  the  demand 
for  further  relaxation  may  require.  When  the  remain- 
ing band  of  fibers  is  made  tense  by  the  hook,  it  is 
slightly  elevated  from  the  sclera,  when  the  fine-pointed 
scissors  are  introduced  beneath  the  conjunctiva,  and 


206  FUNCTIONAL  NERVOUS  AFFECTIONS. 

the  necessary  extension  of  the  wound  is  made  with  an 
extreme  caution  not  to  divide  the  capsular  attachment. 
The  conjunctival  suture  should  in  no  case  be  employed. 
All  bandaging  of  the  eye  or  covers  of  any  description 
are  not  only  needless  but  mischievous.  Bandages  are 
promoters  of  heat,  filth,  and  septicism. 

ESOPHORIA. 

Eso]3horia,  or  "insufficiency  of  the  externi,"  is  an 
exceedingly  common  and  a  very  troublesome  anomaly 
of  the  ocular  muscles.  In  esophoria  the  relative  ten- 
sion of  the  eye-muscles  is  such  that,  if  the  force  of  the 
will  were  to  be  removed,  the  visual  lines  would  ap- 
proach each  other  and  cross  at  a  point  less  distant  than 
that  for  which  the  eyes  are  accommodated.  In  stra- 
bismus convergens  this  tendency  is  carried  to  the  ex- 
tent that  one  visual  line  constantly  deviates  from  the 
direction  of  the  other.  In  esophoria  there  is  habitually 
an  ability  to  bring  the  lines  simultaneously  to  the 
same  point.  The  effort  required  to  continue  this  ad- 
justment may  be,  and  in  the  great  majority  of  in- 
stances is,  made  without  the  direct  consciousness  of 
the  individual,  and  there  is  not  of  necessity  any  ap- 
pearance of  deviation,  although  it  is  not  uncommon  to 
observe  an  appearance  of  insufficient  distance  between 
the  eyes — giving,  in  this  respect,  a  narrow  facial  ex- 
pression disproportionate  to  the  general  features. 

Graefe,  in  his  extensive  writings  upon  the  ocular 
muscles,  devoted  only  a  passing  notice  to  this  condi- 
tion, his  treatise  on  muscular  asthenopia  containing 
but  a  single  paragrajDh  relating  to  it.     In  this,  how- 


SUPPLEMENT.  207 

ever,  lie  was  more  liberal  tlian  most  succeeding  writers, 
and  even  the  latest  text-books  on  ophthalmology  make 
no  reference  to  the  condition.  The  first  notices  of 
cases  of  treatment  of  "  insufiiciency  of  the  externi,"  in 
which  no  strabismus  existed,  and  in  which  important 
results  were  obtained,  were  reported  by  myself  in  va- 
rious papers  from  1876  forward.  In  the  memoir  to 
which  this  discussion  is  supplemental,  more  especial 
consideration  was  devoted  to  this  condition  than  had 
been  given  to  it  in  all  previous  writings,  and  the  many 
instances  of  remarkable  relief  obtained  from  the  cor- 
rection of  this  anomaly  related  therein  precede  any 
considerable  discussion  of  the  subject,  and,  indeed, 
constitute  the  principal  contribution  to  it  up  to  the 
present  time. 

"Insufficiency  of  the  interni"  is  the  condition  to 
which  muscular  asthenopia  has  been  generally  attrib- 
uted. We  have  already  seen  that  hyperphoria  is  an 
element  of  the  first  importance  in  muscular  asthenopia, 
and  a  careful  perusal  of  the  foregoing  memoir  will  con- 
vince the  reader  that  esophoria  is  also  of  equal  signifi- 
cance with,  if  not  of  greater  importance  than,  "insuf- 
ficiency of  the  interni."  It  is  certainly  of  more  fre- 
quent occurrence,  and  is,  in  a  greater  proportion  of 
cases,  attended  with  distant  refiex  disturbances. 

Among  the  symptoms  very  commonly  observed  as 
resulting  from  esophoria,  are  pain  in  the  back  of  the 
head  and  in  the  back  of  the  neck.  Such  pains  often 
succeed  an  hour's  visit  to  a  gallery  of  pictures,  attend- 
ance at  a  public  gathering,  where  one  confines  the  gaze 
for  a  considerable  time  upon  a  speaker ;  and  travel  in  a 


208  FUNCTIONAL  NERVOUS  AFFECTIONS. 

rail-car,  when  tlie  individual,  the  subject  of  esophoria, 
looks  out  upon  the  rapidly-changing  objects  of  the 
landscape,  is  often  the  precursor  of  such  occiipital 
headaches. 

Nervous  exhaustion,  palpitation  of  the  heart,  pain 
between  the  shoulder-blades  and  at  the  lower  ^avt 
of  the  back,  dyspepsia,  and  habitual  constipation  are 
among  the  very  common  reflex  nervous  phenomena  re- 
sulting from  esophoria. 

To  ascertain  the  existence  of  esophoria  and  its  de- 
gree, the  test  for  hyperphoria  having  been  already 
made,  we  first  place  a  prism  of  about  7°  with  its  base 
down  before  one  of  the  eyes  and  cause  the  person  exam- 
ined to  look  at  an  object  twenty  feet  distant.  Double 
vision  results  with  the  image  before  which  the  glass  is 
jDlaced  above  its  fellow.  If,  now,  the  higher  image 
deviates  in  the  direction  of  the  eye  before  which  the 
glass  is  placed,  if  the  deviation  is  homonymous,  there 
is  esojDhoria,  measured  by  the  degree  of  prism,  placed 
with  its  base  out  before  either  eye,  which  brings  and 
holds  the  two  images  exactly  in  the  same  vertical  line. 
In  making  this  examination  hyperopia  or  hyperoj)ic 
astigmatism,  if  of  higher  grade  than  '50  D,  should  be 
corrected  by  appropriate  glasses.  Moderate  degrees  of 
myopia  or  myopic  astigmatism  have  little  influence 
wpon  the  test.  After  determining  the  degree  of  eso- 
phoria by  the  vertical  prism,  the  amount  of  abducting 
power  is  to  be  ascertained.  Prisms  with  the  base  in 
are  employed,  requiring  the  person  examined  to 
make  the  strongest  effort  to  blend  the  double  images. 
The  strongest  prism  which  can  be  overcome  marks  the 


SUPPLEMENT.  209 

power  of  abduction.  This  power  should  be  equal  to 
overcoming  a  prism  of  8°  with  the  base  in. 

Let  us  suppose  that  esoj)horia  of  a  certain  degree 
has  been  found,  and  that  there  is  aiDproximately  a 
corresponding  restriction  of  the  abducting  force.  The 
diagnosis  of  esophoria  of  the  given  amount  is  clear. 
But  if,  by  the  vertical  prism,  no  deviation  is  shown, 
and  there  is  still  a  restricted  abduction,  there  is  proba- 
bly latent  esophoria  equal,  at  least,  to  the  difference 
between  a  prism  of  8°  and  that  with  which  images  can 
be  blended. 

But  let  it  be  supposed  that  a  very  considerable  de- 
gree of  esophoria  is  found  with  a  power  of  abduction 
exceeding  the  standard  given  above.  One  of  two  con- 
ditions must  be  presumed  :  There  may  exist  an  actual 
deviating  tendency  inward,  and  by  constant  efforts  at 
its  correction  the  power  of  the  external  recti  may  have 
been  so  greatly  developed  as  to  enable  the  individual 
to  accomplish  more  than  the  usual  abduction ;  or, 
more  probably,  there  exists  hyperiDlioria.  In  this  later 
case  the  esophoria  may  be  aiDparent,  the  result  of  a 
swinging  movement  given  to  the  eyes  in  the  test,  and 
the  actual  balance  may  be  neither  inward  nor  outward. 
The  utmost  caution  and  great  patience  are  required  in 
the  management  of  this  class  of  cases.  A  condition 
exactly  opposite  the  one  just  supposed  will  be  consid- 
ered in  the  discussion  of  exophoria.  Again,  should 
esophoria  be  found  when  testing  for  the  distant  point, 
and  exophoria  be  shown  in  accommodation,  we  are  to 
suspect  hyperphoria,  and  the  case  should  be  carefully 
observed  until    this  question  is   satisfactorily  deter- 


210  FUNCTIONAL  NERVOUS  AFFECTIONS. 

mined.  After  having  made  tlie  examination  at  the 
distance  of  twenty  feet,  examination  with  the  vertical 
prism  is  made  at  a  distance  of  about  eighteen  inches. 
If  esophoria  is  found,  it  is  esophoria  in  accommoda- 
tion. 

TREATMENT   OF  ESOPHORIA. 

Esophoria  may,  under  certain  circumstances,  be 
treated  by  prismatic  glasses ;  if  refractive  errors  exist, 
the  prismatic  element  may  be  combined  with  the  spher- 
ical, or  cylindrical  glasses. 

This  is  the  method  of  a  crutch,  and  is  inconvenient 
and  by  no  means  uniformly  successful.  Indeed,  suc- 
cessful relief  to  esophoria,  by  means  of  prisms,  would 
appear  to  be  rather  exceptional.  It  is  a  proper  meth- 
od of  treatment  only  when  better  methods  can  not  be 
adopted.  There  are  several  reasons  in  the  nature  of 
such  a  correction  why  it  should  be  unsatisfactory, 
which  need  not  be  discussed  here. 

The  radical  and  best  method  is  tenotomy  of  one  or 
both  of  the  interni,  performed  by  the  method  already 
described  at  page  203.  Before  resorting  to  an  opera- 
tion it  is  always  advisable  that  the  power  of  adduction 
should  be  fully  developed  in  the  manner  that  will  be 
shown  in  the  section  on  exophoria.  An  adducting 
power  of  50°  should  be  shown  prior  to  the  opera- 
tion. 

EXOPHORIA. 

This  is  the  condition  which  has  been  described  in 
text-books  as  "insufficiency  of  the  interni."  The  con- 
dition, however,  differs  in  the  respect  that,  whereas 
"insufficiency  of  the  interni"  has,  by  Graefe  and  in 


I 


SUPPLEMENT.  211 

the  text-books  generally,  been  determined  by  the  dot- 
and-line  test  at  a  near  point,  exophoria  is  the  condition 
found  at  a  distance  when  no  accommodation  is  em- 
ployed. The  condition  described  in  text-books  is  here 
known  as  exophoria  in  accommodation.  The  condi- 
tions found  by  the  tests  known  as  the  "cover- tests," 
and  by  holding  an  object  near  the  eyes  to  observe  the 
deviation  of  one  or  other,  are  perhaps  better  included 
in  the  limits  of  the  subject  of  strabismus. 

Exophoria  is  discovered  by  means  similar  to  those 
described  for  esophoria.  If,  with  the  vertical  prism, 
the  images  cross,  if  the  image  seen  by  the  right  eye  is 
at  the  left,  and  that  seen  by  the  left  is  at  the  right  of 
the  other,  exophoria  exists  in  the  degree  measured  by 
the  prism  with  its  base  inward,  required  to  bring  the 
two  images  to  a  vertical  line. 

Exophoria  in  accommodation  is  tested  in  the  same 
manner,  but  at  the  near  point.  If,  with  a  certain  de- 
gree of  exophoria,  abduction  exceeds  8°,  we  have  an 
undoubted  condition  of  deviating  tendency  outward. 
If,  on  the  other  hand,  exophoria  is  attended  with  re- 
striction of  abductive  force,  we  are  to  presume  that 
hyperphoria  exists,  and  that,  as  in  the  case  of  esopho- 
ria, under  the  reverse  conditions,  the  apparent  exo- 
phoria is  the  result  of  the  swing  resulting  from  the 
hyperphoria. 

Exophoria  in  accommodation  is  often  associated 
with  esophoria,  and  should  never  under  such  circum- 
stances be  mistaken  for  an  actual  tendency  of  the  eyes 
to  deviate  outward. 

The  symptoms  of  exophoria  are,  perhaps,  more  fre- 


212  FUNCTIONAL  NERVOUS  AFFECTIONS. 

quently  than  esoplioria,  local.  As  a  result  of  tliis 
anomaly,  the  condition  of  muscular  asthenopia  is  com- 
mon, and  is  indeed  the  only  condition  usually  associated 
with  this  anomaly  in  the  literature  of  ophthalmology. 

In  muscular  asthenopia  there  is  a  sense  of  painful 
fatigue  of  the  eyes  after  close  work  or  reading ;  an  in- 
clination for  the  letters  or  words  of  the  page  to  run 
together,  or  for  one  word  to  find  itself  superposed  upon 
another.  A  feeling  of  tension  and  dull  pain  over  the 
brows  and  in  the  back  of  the  head  is  experienced,  the 
latter,  perhaps,  more  especially  after  a  few  hours  have 
elapsed  since  the  use  of  the  eyes. 

The  more  distant  manifestations  of  exophoria  are 
the  neurasthenic  symptoms,  which  have  already  been 
mentioned  as  resulting  from  other  forms  of  hetero- 
X:)horia.  It  may  be  accepted  as  a  general  fact,  how- 
ever, that  the  symptoms  of  exophoria  are  more  likely 
to  be  local,  those  of  esophoria  more  general.  The 
effort  made  in  exophoria  to  hold  the  visual  lines  in  ad- 
justment for  reading  or  other  close  work  results  in 
local  fatigue  and  pain.  That  made  in  esoi:)horia  is 
attended  with  less  local  strain  at  the  moment,  but  is  a 
perpetual  source  of  disturbance  of  the  relations  be- 
tween the  accommodative  and  converging  forces.  It  is 
a  condition  of  nervous  perplexity,  experienced  both 
when  looking  at  near  and  far  i)oints. 

In  the  diagnosis  of  all  these  conditions  of  hyper- 
phoria, esophoria,  and  exophoria,  we  are  in  every  case 
to  take  into  account  the  fact  that  the  manifest  condi- 
tion does  not  always  represent  the  absolute  deviating 
tendency. 


SUPPLEMENT.  213 

Graefe,  and  many  who  have  followed  him,  regarded 
insuflBciency  of  the  interni  as  a  condition  found  mostly 
with  cases  of  considerable  myopia.  If  we  accept  the 
test  at  the  near  point  as  indicating  such  insufficiency, 
it  may  be  true  that  the  condition  is  so  frequent  with 
myopia  as  to  be  peculiarly  an  associated  state ;  but 
exophoria  as  here  described  is  less  frequently  found 
with  myopia  than  is  esophoria. 

In  the  condition  of  orthophoria  the  adducting 
power  should  be  equal  to  an  ability  to  overcome 
prisms  amounting  to  50°,  when  the  object  is  placed  at 
the  specified  distance,  twenty  feet.  Even  eyes  with 
well-balanced  muscles  may  not,  in  the  absence  of  a 
certain  muscular  facility,  be  able  to  accomplish  this  at 
the  first  trial.  A  few  attempts  will  generally  be  re- 
warded with  complete  success.  In  exophoria  the  ab- 
ducting power  may  be  much  less  than  this,  and  when 
a  considerable  reduction  of  this  force  is  associated  with 
exophoria,  as  shown  by  the  vertical-prism  test,  it  is  an 
additional  evidence  of  the  vicious  tendency.  Insuffi- 
cient adducting  force  is  not,  however,  always  indica- 
tive of  exophoria,  nor  is  it  always  an  element  of  ex- 
ophoria. Indeed,  in  many  cases  of  very  considerable 
outward  deviating  tendency,  the  power  of  adduction  is 
exercised  with  remarkable  vigor  and  to  the  full  extent 
that  can  be  desired.  On  the  other  hand,  a  feeble  ab- 
ducting power  may  be  found  where  there  is  no  exo- 
phoria, and  where  even  esophoria  of  high  degree 
exists.  In  these  cases  the  failure  of  abducting  power 
may  arise,  among  other  things,  from  fatigue  of  the 
muscles  or  from  disuse.     This  latter  reason  is  pecul- 


214  FUNCTIONAL  NERVOUS  AFFECTIONS. 

iarly  marked  in  certain  cases  of  esoplioria.  In  such 
cases  there  has  been,  during  the  history  of  the  patient, 
little  need  of  performing  a  positive  act  of  adduction. 
Habitually  the  external  muscles  have  by  severe  ten- 
sion, maintained  the  parallelism  of  the  visual  lines,  and 
when  it  is  required  to  converge  these  lines  the  act  is 
performed,  not  altogether  by  the  muscular  contraction 
of  the  interni,  but  largely  by  their  natural  elasticity, 
acting  when  the  opposing  tension  of  the  externi  is 
removed. 

TREATMENT   OF  EXOPHORIA. 

In  the  condition  of  insufficient  abducting  power, 
such  as  may  be  found  with  moderate  exophoria,  with 
no  especial  deviating  tendency,  or  with  esophoria,  the 
adduction  may  be  greatly  improved  by  gymnastic  ex- 
ercises of  the  interni  conducted  by  the  aid  of  prisms. 

In  these  exercises  the  eyes  are  required  to  unite 
images  in  overcoming  gradually  increasing  obstacles. 
A  prism  of  a  few  degrees,  perhaps  10°,  is  placed, 
base  out,  before  one  of  the  eyes,  while  gazing  at  a 
lighted  candle  placed  at  twenty  feet  distance,  when 
an  effort  is  at  once  made  to  prevent  diplopia.  As 
soon  as  the  images  are  blended,  another  prism,  of  per- 
haps less  degree,  is  placed  in  the  same  manner ;  the 
images  being  united,  a  stronger  prism  takes  the  place 
of  one  of  those  already  in  place,  or  one  is  added  to 
those  already  in  position.  Thus,  little  by  little,  the 
eyes  are  required  to  overcome  prisms  until  the  images 
can  no  longer  be  united.  Then  all  the  glasses  are  re- 
moved and  the  process  is  repeated ;  with  each  repeti- 
tion something  may  be  gained.     The  exercise  should 


SUPPLEMENT.  215 

not  be  continued  at  a  single  sitting  more  than  five  or 
six  minutes,  and  only  a  single  sitting  daily  is  desirable. 

By  this  means  the  adducting  power  can,  in  most 
cases,  be  raised  after  a  few  exercises  to  the  desired 
point.  It  is  an  interesting  fact  that  in  most  cases  of 
moderate  exophoria,  or  of  no  especial  heterophoria,  the 
exercise  is  attended  with  much  more  speedy  results 
than  in  a  certain  proportion  of  cases  of  esophoria. 

The  effect  of  such  exercises  upon  the  eyes  is  very 
often  extremely  salutary.  With  greater  freedom  of 
muscular  action  comes  a  sense  of  relief  from  nervous 
strain,  which  is  often  of  a  most  gratifying  character. 
Such  an  exercise  is  in  no  way  related  to  the  practice 
sometimes  adopted,  and  which  should  be  condemned, 
of  requiring  the  patient  to  gaze  for  a  length  of  time  at  a 
near  object.  In  this  latter  case  the  act  of  accommoda- 
tion is  associated  with  the  convergence  of  the  optic  axis, 
and  there  is  simply  an  exaggeration  of  the  accustomed 
strain.  In  the  exercise  Vt^ith  prisms  the  accommoda- 
tion is  at  rest,  and  the  action  of  the  recti  muscles  is 
almost  completely  dissociated  from  that  of  the  ciliary 
muscles.  The  exercise  then  selects  the  muscles  to  be 
acted  upon. 

In  exoiDhoria  of  a  moderate  degree,  prisms  with  the 
base  in  may  be  found  useful  in  reading.  It  is  in  this 
condition,  of  all  the  forms  of  heterophoria,  that  prisms 
are  most  likely  to  prove  of  any  permanent  use.  In 
general,  even  for  moderate  exophoria,  a  radical  relief 
is  to  be  preferred  to  the  perpetual  employment  of 
glasses. 

The  method  for  performing  tenotomy,  as  described 

15 


216  FUNCTIONAL  NEEVOUS  AFFECTIONS. 

already,  should  be  followed  closely  in  tMs  as  in  other 
conditions  of  heterophoria.  The  advice  given  by 
Graefe,  and  followed  up  to  the  present  time  in  the 
text-books,  to  sever  the  externus  completely  and  to 
induce  homonymous  diplopia,  is  not  to  be  followed, 
Graefe  performed  his  operations,  for  the  most  part,  in 
cases  of  extreme  myopia.  In  these  cases,  the  vision  of 
his  patients  being  defective  at  a  distance,  an  insuffi- 
ciency of  the  extern!  did  not  appear  to  be  a  matter  of 
serious  consequence.  It  may  well  be  supposed  also 
that,  for  the  most  part,  his  cases  were  not  of  the  class 
which  has  here  been  described  as  exoj)horia,  but  cases 
of  positive  but  slight  strabismus. 

The  result  of  a  tenotomy  for  exophoria  should  not 
be  homonymous  diplopia,  nor  even  esophoria  to  ex- 
ceed 1°  or  2°,  and  the  abducting  power  should  im- 
mediately after  the  operation  not  be  less  than  suffi- 
cient to  overcome  a  prism  of  6°.  Should  exophoria 
again  manifest  itself,  the  operation  may  be  made  upon 
the  opposite  eye ;  and  it  is  better  to  make  repeated 
operations  than  in  any  instance  to  obtain  diplopia  or 
considerable  esophoria. 

The  study  of  muscular  anomalies,  in  which  gross 
deviations  are  found,  strabismus  concomitans,  or  stra- 
bismus from  paralysis,  constitutes  a  subject  of  much 
interest  to  the  student  of  the  effects  of  ocular  anoma- 
lies upon  the  nervous  system.  Cases  of  this  class  are 
much  less  frequent  than  those  already  discussed,  and, 
to  a  considerable  extent,  the  princiiDles  which  have 
been  laid  down  respecting  the  more  ordinary  class  of 
anomalies  will  apply  to  non-paralytic  strabismus. 


SUPPLEMENT.  217 

It  is  the  purpose  of  tMs  supplement  only  to  intro- 
duce tlie  practitioner  into  a  field  not  usually  investi- 
gated, except  by  specialists,  and  to  assist  liim  in  his 
efforts  to  find  and  to  remove  a  class  of  causes  largely 
instrumental  in  inducing  an  important  class  of  dis- 
orders. 

To  add  largely  to  what  has  been  said  would  be  out- 
side the  design  of  this  work.  The  author,  therefore, 
reserves  the  discussion  of  his  personal  views  upon 
strabismus  for  a  future  work  upon  the  ocular  muscles. 


THE  EJS^D. 


An  Atlas  of  Clinical  Microscopy. 

By  ALEXANDER  PETER,  M.  D.  Translated  and  edited  by  Alfred 
C.  GiRAED,  !M.  D.,  Assistant  Surgeon  United  States  Army.  First 
American,  from  ttie  Manuscript  of  the  second  German  edition, 
with  Additions. 

Ninety  Plates,  with  One  Hundred  and  Five  Illustrations,  Chromo-Lithographs. 
Square  8vo  volume.     Cloth,  $6.00. 

"  All  who  are  interested  in  clinical  microscopy  will  be  pleased  with  the  design 
and  execution  of  this  work,  and  will  feel  under  obligation  to  the  author,  trans- 
lator, and  publishers  for  placing  so  valuable  a  work  in  their  hands.  The  plates 
in  which  are  figured  the  various  urinary  inorganic  deposits  are  especially  fine,  and 
the  various  forms  of  tube-casts,  hyaline,  waxy,  epithelial,  and  mucous,  are  depicted 
with  great  fidelity  and  accuracy." — Philadelphia  Medical  Times. 

"  To  those  students  and  practitioners  of  medicine  who  are  interested  in  micro- 
scopical work  and  who  are  familiar  with  the  use  of  this  valuable  aid  to  human 
vision  in  the  study  of  nature,  the  present  work  will  prove  of  incalculable  value, 
since  it  represents  the  original  work  of  an  accomplished  microscopist  and  artist. 
Accompanying  the  plates  is  a  text  of  explanatory  notes  showing  the  various 
methods  of  working  with  the  microscope  and  the  significance  of  what  is  observed. 
The  plates  have  been  most  handsomely  printed.  We  have  seen  nothing  in  this 
special  line  of  study  that  will  compare  in  point  of  accuracy  of  detail  and  artistic 
effect  to  the  work  under  consideration." — Maryland  Medical  Journal. 

The  Use  of  the  Microscope  in  Clinical 
and  Pathological  Examinations. 

By  Dr.  CARL  FRIEDLAENDER,  Privat-Docenfc  in  Pathological 
Anatomy  in  Berlin.  Translated  from  the  enlarged  and  improved 
second  edition,  by  Henet  C.  Coe,  M.  D.,  etc. 

With  a  Chromo-Lithograph.    12mo,  195  pages,  with  copious  Index.    Cloth,  $1.00. 

"We  are  very  much  pleased  to  see  Dr.  Friedlaender's  little  book  make  its 
appearance  in  English  dress.  As  we  have  a  practical  acquaintance  of  the  Ger- 
man edition  since  its  appearance,  we  can  speak  of  it  in  terms  of  unqualified 
praise.  .  .  .  Every  one  doing  pathological  work  should  have  this  httle  book  in  his 
possession.  The  translator  has  done  his  work  well,  and  has  certainly  conferred 
a  great  favor  on  all  microscopists  by  placing  within  the  reach  of  every  one  the 
work  of  so  accomplished  a  teacher  as  Dr.  Carl  Friedlaender." — Canada  Medical 
and  Surgical  Journal. 

"  Much  good  has  been  done  in  placing  this  little  work  in  the  hands  of  the 
profession.  The  technique  of  preparing,  cutting,  and  staining  specimens  is  given 
at  some  length ;  also  rules  for  the  examination  of  the  various  bodily  fluids  in 
both  health  and  disease.  The  use  of  the  microscope  with  high  powers,  immer- 
sion lenses,  and  other  accessories,  is  explained  very  clearly.  It  is  a  very  readable 
volume,  even  for  those  not  engaged  in  actual  laboratory  work.  A  chromo-litho- 
graph  shows  the  various  forms  of  disease-germs  which  have  been  definitely  iso- 
lated."— Medical  Record. 


New  York :  D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


A  TREATISE  ON  INSANITY,  IN  ITS  MEDI- 

CAL  RELATIONS. 

By  WILLIAM  A.  HAMMOND,  M.  D., 

Surgeon-General  TJ.  S.  Army  (retired  list) ;  Professor  of  Diseases  of  the  Mind  and 

Nervous  System,  in  the  New  York  Post-Graduate  Medical  School ; 

President  of  the  American  Neurological  Association,  etc. 

1  vol.,  8vo,  767  pp.    Cloth,  $5.00 ;  sheep,  $6.00. 


In  this  work  the  author  has  not  only  considered  the  subject  of  Insanity,  but 
has  prefixed  that  division  of  his  work  with  a  general  view  of  the  mind  and  the 
several  categories  of  mental  faculties,  and  a  full  account  of  the  various  causes  that 
exercise  an  influence  over  mental  derangement,  such  as  habit,  age,  sex,  hereditary 
tendency,  constitution,  temperament,  instinct,  sleep,  dreams,  and  many  other  factors. 

Insanity,  it  is  believed,  is  in  this  volume  brought  before  the  reader  in  an  origi- 
nal manner,  and  with  a  degree  of  thoroughness  which  can  not  but  lead  to  impor- 
tant results  in  the  study  of  psychological  medicine.  Those  forms  which  have  only 
been  incidentally  alluded  to  or  entirely  disregarded  in  the  text-books  hitherto  pub- 
lished are  here  shown  to  be  of  the  greatest  interest  to  the  general  practitioner  and 
student  of  mental  science,  both  from  a  normal  and  abnormal  stand-point.  To  a 
great  extent  the  work  relates  to  those  species  of  mental  derangement  which  are 
not  seen  within  asylum  walls,  and  which,  therefore,  are  of  special  importance  to 
the  non-asylum  physician.  Moreover,  it  points  out  the  symptoms  of  Insanity  in 
its  first  stages,  during  which  there  is  most  hope  of  successful  medical  treatment, 
and  before  the  idea  of  an  asylum  has  occurred  to  the  patient's  friends. 


A  TREATISE  ON  THE   DISEASES  OF  THE 

NERVOUS  SYSTEM. 

By  WILLIAM  A.  HAMMOND,  M.D., 

Surgeon-General  U.  S.  Army  (retired  list) ;  Professor  of  Diseases  of  tlie  Mind  and 

Nervous  System,  in  the  New  York  Post-Graduate  Medical  School ; 

President  of  the  American  Neurological  Association,  etc. 

Seventh  edition,  rewritten,  enlarged,  and  improved.    In  one  large  8ro  vol.  of  929  pp.,  with 
Complete  Index  and  150  lUmtrations.    Cloth,  $5.00 ;  s/uep  or  half  russia,  $6.00. 

The  work  has  received  the  honor  of  a  French  translation  by  Dr.  Labadlc- 
Lagrave,  of  Paris,  and  an  Italian  translation  bv  Professor  Diodato  Borrelli,  of  the 
Eoyal  University,  is  now  going  through  the  press  at  Naples. 


".    '™™°°       ^^'"^  ^^^  °°^  ^^'^^  ^°^^  experience  is  larore,  his  convictions 

before    tlie    profession  for  many  years,  are  positive,  and  he  can  set  them  forth 

and  Its  characteristics  are  verv  generally  cleariy  and  attractively.    It  Ls  not  surpris- 

known.    The  present  edition  has  a  good  ing  that  his  book  has  been  a  very  popu- 


quaUties  of  a  successful  author.    His  prac- 


New  York:  D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


A    PRACTICAL    TREATISE    ON   MATERIA 

MEDICA  AND  THERAPEUTICS. 

By  ROBERTS  BAETHOLOW,  M.  A.,  M.  D., 
Professor  of  Materia  Medica  and  Therapeutics  in  the  Jefferson  Medical  College,  etc. 

Fifth  edition.    Bevised,  enlarged,  and  adapted  to  "  The  New  Pharmaccpaia:'    1  vol.,  8vo. 
Cloth,  $5.00 ;  sheep,  86.00. 


From  Peeface  to  Fifth  Edition. 
"  The  appearance  of  the  sixth  decennial  revision  of  the  '  United  States 
Pharmacopoeia '  has  imposed  on  me  the  necessity  of  preparing  a  new  edi- 
tion of  this  treatise.  I  have  accordingly  adapted  the  work  to  the  official 
standard,  and  have  also  given  to  the  whole  of  it  a  careful  revision,  incor- 
porating the  more  recent  improvements  in  the  science  and  art  of  thera- 
peutics. Many  additions  have  been  made,  and  parts  have  been  rewritten. 
These  additions  and  changes  have  added  about  one  hundred  pages  to  the 
body  of  the  work,  and  increased  space  has  been  secured  in  some  places  by 
the  omission  of  the  references.  In  the  new  material,  as  in  the  old,  prac- 
tical utility  has  been  the  ruling  principle,  but  the  scientific  aspects  of 
therapeutics  have  not  been  subordinated  to  a  utilitarian  empiricism.  In 
the  new  matter,  as  in  the  old,  careful  consideration  has  been  given  to  the 
physiological  action  of  remedies,  which  is  regarded  as  the  true  basis  of  all 
real  progress  in  therapeutical  science;  but,  at  the  same  time,  I  have  not 
been  unmindful  of  the  contributions  made  by  properly  conducted  clinical 
observations." 

"  He  is  well  known  as  a  zealous  student  pape.    Dr.  Bartholow,  like  another  expe- 

of  medical  science,  an  acute  observer,  a  ricnccd  teacher — Professor  von  Schroff,  of 

gfood  writer,  a  skilled  practitioner,  and  an  Vienna — picks  out  the  most    important 

ingenious,  bold,  though  sometimes  reck-  physiological  and  therapeutical  actions  of 

less  investigator.     His  present  book  will  each  drug,  and  gives  them  in  a  short  and 

receive  the  cordial  welcome  which  it  de-  somewhat    dogmatic    manner.      Having 

serves,  and  which  the  honorable  position  formed    his  own    conclusions,   he  gives 

that  he  has  won  entitles  him  to  demand  them  to  the  public,  without  entering  so 

for  it.  .  .  .  Dr.  Bartholow's  treatise  has  fully  as  Wood  into  the  experiments  on 

the  merit — and  a  great  merit  it  is— of  in-  which  they  are  founded." — IVaditioner 

cludincr  diet  as  well  as  drugs.  .  .  .  His  {London). 

^^^.  ^f'ti  ^°n  ^^Vo.^e  or  depreciate  the  »  ^             ^    ;t    ^^^          ^^^^  Dr. 

itZ^l^  .  ^  ^T'"'f^  ^"f '  •''*  ?  '"''"■  Bartholow  has,  to  a  great  extent,  succe.s- 

S.Z  -^  f     '■'V^'°''''^  profes..ional  expe-  ^^j,      ^     ^^   ^.'j^^  ^^^   difficulties  of  his 

tW^^ri.V-.  1  ''^"'  n^^'^\}^  ^^^^^^  classification,  and  his  book  has  also  other 

tW,-r  rfw^ni  •    Tl'T  "■   ^?J"^^/^  "P°'^  merits  to  commend  it.    It  is  largely  origi- 

J^?.VLP;Ti^"  ?/^'^^e^  nal.    By  this  we  mean  that  it  gives  tie 

Journal  of  the  Medical  Sciences.  ^^^^^^^  ^^^  ^^^  ^^^^^^,^  ^^^  ^^^j^  „^i 

"  After  looking  through  the  work,  observation,  instead  of  a  catalogue  of  the 
most  readers  will  agree  with  the  author,  contending  statements  of  his  predeces- 
whose  long  training  shows  itself  on  every    sors." — Tlie  Doctor  {London). 


New  York :  D.  APPLETON  &  CO.,  1,  3,  k  5  Bond  Street. 


A  TREATISE  ON  THE  PRACTICE  OF  MEDI- 

CINE,  for  the  Use  of  Students  and  Practitioners. 

By  EOBEETS  BAETHOLOW,  M.  A.,  M.  D.,  LL.  D., 
Professor  of  Materia  Meclica  and  General  Therapeutics  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia ;  recently  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Medical  College  of  Ohio,  in  Cincinnati,  etc.,  etc. 

Fifth  edition,  revised  and  enlarged.     8vo.     Cloth,  $5.00  ;  shee^  or  half  rusiia,  $6.00. 

The  same  qualities  and  characteristics  which  have  rendered  the  author's  "  Trea- 
tise on  Materia  Medica  and  Therapeutics  "  so  acceptable  are  equally  uianitcst  in  this. 
It  is  clear,  condensed,  and  accurate.  The  whole  work  is  brought  up  on  a  level  with, 
and  incorporates,  the  latest  acquisitions  of  medical  science,  and  may  be  depended  on 
to  contain  the  most  recent  information  up  to  the  date  of  publicatioa. 


"  Probably  the  crowning  feature  of  the 
work  before  us,  and  tliat  which  will  make 
it  a  favorite  with  practitioners  of  medi- 
cine, is  its  admirable  teaching  on  tlie  treat- 
ment of  disease.  Dr.  Bartliolow  has  no 
sympathy  with  the  modern  school  of  ther- 
apeutical nihilists,  but  possesses  a  whole- 
some belief  in  the  value  and  efficacy  of 
remedies.  He  does  not  fail  to  indicate, 
however,  that  the  power  of  remedies  is 
limited,  that  specifics  are  few  indeed,  and 
that  routine  and  reckless  medication  are 
dangerous.  But  throughout  the  eutire 
treatise  in  connection  with  each  malady 
are  laid  down  well-defluod  methods  and 
true  principles  of  treatment.  It  may  bo 
said  with  justice  that  this  part  of  the  work 
rests  upon  thoroughly  scientific  and  prac- 
tical priaciples  of  therapeutics,  and  is  ex- 
ecuted in  a  masterly  manner.  No  work  on 
the  practice  of  medicine  with  which  we 
are  acquainted  will  guide  the  practitioner 
in  all  the  details  of  treatment  so  well  as 
the  one  of  whicli  we  are  writing." — Amer- 
ican Practitioner. 

"  The  work  as  a  whole  is  peculiar,  in 
that  it  is  stamped  with  the  individuality 
of  its  author.  The  reader  is  made  to  feel 
that  the  e.viJerience  upon  which  this  work 
is  based  is  real,  that  the  statements  of  the 
writer  are  foimded  on  firm  convictions, 
and  that  throughout  the  conclusions  are 
eminently  sound.  It  is  not  an  elaborate 
treatise,  neither  is  it  a  manual,  but  half- 
way between ;  it  may  be  considered  a 
thoroughly  useful,  trustworthy,  and  prac- 


tical guide  for  the  general  practitioner." — 
Medical  Record. 

"  It  may  be  said  of  so  small  a  book  on 
so  large  a  subject,  that  it  can  be  only  a 
sort  of  compendium  or  vade  mecum.  But 
this  criticism  will  not  be  just.  For,  while 
the  author  is  master  in  the  ait  of  conden- 
sation, it  will  be  found  that  no  essential 
points  have  been  omitted.  Mention  is 
made  at  least  of  every  unequivocal  symp- 
tom in  the  narration  of  the  signs  of  dis- 
ease, and  characteristic  symptoms  are 
held  well  up  in  the  tbregroimd  in  every 
case." — Cincinnati  Lancet  and  Cli?iic. 

"  Dr.  Bartholow  is  known  to  be  a  very 
clear  and  explicit  ■writer,  and  in  this  work, 
which  we  take  to  be  his  special  life-work, 
we  are  very  sure  his  many  friends  and  ad- 
mirers will  not  be  disappointed.  We  can 
not  say  more  than  this  without  attempt- 
ing to  follow  up  the  details  of  the  plan, 
which,  of  course,  would  be  useless  in  a 
brief  book-notice.  We  can  only  add  that 
we  feel  confident  the  verdict  of  the  pro- 
fession will  place  Dr.  Bartholow's  '  Prac- 
tice '  among  the  standard  te.xt-books  of 
the  day." — Cincinnati  Obstetric  Gazette. 

"  The  book  is  marked  by  an  absence  of 
all  discussion  of  the  latest,  fine-spun  theo- 
ries of  points  in  pathology  ;  by  the  clear- 
ness with  which  points  in  diagnosis  are 
stated;  by  the  conciseness  and  perspicuity 
of  its  sentences  ;  by  the  abundance  of  the 
author's  therapeutic  resources ;  and  by 
the  copiousness  of  its  illustrations." — Ohio 
Medical  Recorder,    - 


NeTY  York :  D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


September^  18S7. 

MEDICAL 

AND 

hygie:^ic  works 


PUBLISHED   BY 


D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street,  New  York 


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BARTHOLOW  (ROBERTS).  On  the  Antagonism  between  Medicines  and  be- 
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CORNING  (J.  L.).  Brain  Exhaustion,  with  some  Preliminary  Considerations 
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ings.  IX.  The  Nervous  System. 

HOFFMANN-ULTZMANN.  Analysis  of  the  Urine,  with  Special  Reference 
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JONES  (II.  MACNxiUGHTON).  Practical  Manual  of  Diseases  of  Women  and 
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MARKOE  (T.  M.).  A  Treatise  on  Diseases  of  the  Bones.  With  Illustrations. 
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and  20,  1884.     Small  8vo.     Cloth,  $5.00. 

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VAN  BUREN  (W.  H.).  Lectures  upon  Diseases  of  the  Rectum,  and  the  Sur- 
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Second  edition,  revised  and  enlarged.    8vo.     Cloth,  $3.00;  sheep,  $4.00. 

VAN  BUREN  (W.  H.).  Lectures  on  the  Principles  and  Practice"  of  Surgery. 
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WAGNER  (RUDOLF).  Hand-Book  of  Chemical  Technology.  Translated  and 
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Crookes.     With  336  Illustrations.     Svo.     Cloth,  $5.00. 

WALTON  (GEORGE  E.).  Mineral  Springs  of  the  United  States  and  Oanadas. 
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etc.     Second  edition,  revised  and  enlarged.     12mo.     Cloth,  $2.00. 

WEBBER  (S.  G.).  A  Treatise  on  Nervous  Diseases :  Their  Symptoms  and 
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WELLS  (T.  SPENCER).    Diseases  of  the  Ovaries.    Svo.    Cloth,  $4.50. 

WYETH  (JOHN  A.).  A  Text-Book  of  Surgery :  General,  Operative,  and  Me- 
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WYLIE  (WILLIAM  G.).  Hospitals:  Their  History,  Organization,  and  Con- 
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UNIVERSITY  OF  CALIFORNIA  LIBRARY 

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